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Demeestere J, Qureshi MM, Vandewalle L, Wouters A, Strbian D, Nogueira RG, Nagel S, Yamagami H, Puetz V, Abdalkader M, Haussen DC, Mohammaden MH, Möhlenbruch MA, Olivé-Gadea M, Winzer S, Ribo M, Michel P, Marto JP, Tanaka K, Yoshimura S, Martinez-Majander N, Caparros F, Henon H, Tomppo L, Dusart A, Bellante F, Ramos JN, Jesser J, Sheth SA, Ortega-Gutiérrez S, Siegler JE, Nannoni S, Kaesmacher J, Dobrocky T, Salazar-Marioni S, Farooqui M, Virtanen P, Ventura R, Zaidi SF, Castonguay AC, Uchida K, Puri AS, Sakai N, Toyoda K, Farzin B, Masoud HE, Klein P, Bui J, Rizzo F, Kaiser DPO, Desfontaines P, Strambo D, Cordonnier C, Lin E, Ringleb PA, Roy D, Zaidat OO, Fischer U, Raymond J, Lemmens R, Nguyen TN. Outcomes of Bridging Intravenous Thrombolysis Versus Endovascular Therapy Alone in Late-Window Acute Ischemic Stroke. Stroke 2024; 55:1767-1775. [PMID: 38748598 DOI: 10.1161/strokeaha.124.046495] [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: 01/11/2024] [Accepted: 04/26/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Studies comparing bridging intravenous thrombolysis (IVT) with direct endovascular therapy (EVT) in patients with acute ischemic stroke who present late are limited. We aimed to compare the clinical outcomes and safety of bridging IVT in patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent EVT 6 to 24 hours after time last known well. METHODS We enrolled patients with anterior circulation large vessel occlusion stroke and a National Institutes of Health Stroke Scale score of ≥6 from 20 centers across 10 countries in the multicenter retrospective CLEAR study (CT for Late Endovascular Reperfusion) between January 2014 and May 2022. We used inverse probability of treatment weighting modeling adjusted for clinical and imaging confounders to compare functional outcomes, reperfusion success, symptomatic intracranial hemorrhage, and mortality between EVT patients with and without prior IVT. RESULTS Of 5098 patients screened for eligibility, we included 2749 patients, of whom 549 received bridging IVT before EVT. The timing of IVT was not recorded. Witnessed stroke onset and transfer rates were higher in the bridging IVT group (25% versus 12% and 77% versus 55%, respectively, P value for both <0.0001), and time intervals between stroke onset and treatment were shorter (time last known well-start of EVT median 560 minutes [interquartile range, 432-791] versus 724 minutes [interquartile range, 544-912]; P<0.0001). After adjustment for confounders, there was no difference in functional outcome at 3 months (adjusted common odds ratio for modified Rankin Scale shift, 1.03 [95% CI, 0.89-1.19]; P=0.72) or successful reperfusion (adjusted odds ratio, 1.19 [95% CI, 0.81-1.75]; P=0.39). There were no safety concerns associated with bridging IVT versus direct EVT (symptomatic intracranial hemorrhage: adjusted odds ratio, 0.75 [95% CI, 0.38-1.48]; P=0.40; mortality: adjusted odds ratio, 1.14 [95% CI, 0.89-1.46]; P=0.31). Results were unchanged when the analysis was limited to patients who received IVT >6 hours after last known well. CONCLUSIONS In patients with an anterior circulation large vessel occlusion stroke who underwent EVT 6 to 24 hours from last known well, bridging IVT was not associated with a difference in outcomes compared with direct EVT. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.
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Affiliation(s)
- Jelle Demeestere
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Muhammad M Qureshi
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Radiation Oncology (M.M.Q.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Lieselotte Vandewalle
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Anke Wouters
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Daniel Strbian
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Raul G Nogueira
- Neurology, Neurosurgery, University of Pittsburgh Medical Center, MA (R.G.N.)
- Neurology, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.H.M.)
| | - Simon Nagel
- Neurology, Klinikum Ludwigshafen, Germany (S.N.)
- Neurology (S.N., P.A.R.), Heidelberg University Hospital, Germany
| | | | - Volker Puetz
- Neurology (V.P., S.W.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Mohamad Abdalkader
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Diogo C Haussen
- Neurology, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.H.M.)
| | | | | | - Marta Olivé-Gadea
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Simon Winzer
- Neurology (V.P., S.W.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Marc Ribo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Patrik Michel
- Neurology, Lausanne University Hospital and University of Lausanne, Switzerland (P.M., D.S.)
| | - João Pedro Marto
- Neurology (J.P.M., R.V.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Kanta Tanaka
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K. Tanaka, K. Toyoda)
| | | | - Nicolas Martinez-Majander
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Francois Caparros
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Hilde Henon
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Liisa Tomppo
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Anne Dusart
- Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium (A.D., F.B.)
| | - Flavio Bellante
- Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium (A.D., F.B.)
| | - João Nuno Ramos
- Radiology (J.N.R.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Jessica Jesser
- Neuroradiology (M.A.M., J.J.), Heidelberg University Hospital, Germany
| | - Sunil A Sheth
- Neurology, UTHealth McGovern Medical School, Houston, TX (S.A.S., S.S.-M.)
| | | | | | - Stefania Nannoni
- Clinical Neurosciences, University of Cambridge, United Kingdom (S.N.)
| | - Johannes Kaesmacher
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D.)
| | - Tomas Dobrocky
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D.)
| | | | | | - Pekka Virtanen
- Radiology (P.V.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Rita Ventura
- Neurology (J.P.M., R.V.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Syed F Zaidi
- Neurology, University of Toledo, OH (S.F.Z., A.C.C.)
| | | | - Kazutaka Uchida
- Neurosurgery, Hyogo Medical University, Nishinomiya, Japan (S.Y., K.U.)
| | - Ajit S Puri
- Interventional Neuroradiology, University of Massachusetts Memorial Medical Center, Worcester (A.S.P.)
| | - Nobuyuki Sakai
- Neurovascular Research, Kobe City Medical Center General Hospital, Japan (N.S.)
| | - Kazunori Toyoda
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K. Tanaka, K. Toyoda)
| | - Behzad Farzin
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | | | - Piers Klein
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Jenny Bui
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
| | - Federica Rizzo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Daniel P O Kaiser
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Institute of Neuroradiology (D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | - Davide Strambo
- Neurology, Lausanne University Hospital and University of Lausanne, Switzerland (P.M., D.S.)
| | - Charlotte Cordonnier
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Eugene Lin
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH (E.L., O.O.Z.)
| | - Peter A Ringleb
- Neurology (S.N., P.A.R.), Heidelberg University Hospital, Germany
| | - Daniel Roy
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH (E.L., O.O.Z.)
| | - Urs Fischer
- Neurology, University Hospital Basel, Switzerland (U.F.)
| | - Jean Raymond
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | - Robin Lemmens
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Thanh N Nguyen
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024; 403:2820-2836. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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Kytö V, Åivo J, Ruuskanen JO. Intensity of statin therapy after ischaemic stroke and long-term outcomes: a nationwide cohort study. Stroke Vasc Neurol 2024:svn-2024-003230. [PMID: 38876780 DOI: 10.1136/svn-2024-003230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/04/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Statins are essential for secondary prevention after ischaemic stroke (IS). However, statin intensity recommendations differ, and there is a concern about intracerebral haemorrhage (ICH). We studied the long-term impacts of initial statin intensity following IS. METHODS Consecutive patients using high-intensity, moderate-intensity or low-intensity statin early after IS (n=45 512) were retrospectively studied using national registries in Finland. Differences were adjusted using multivariable regression. The primary outcome was all-cause death within 12-year follow-up (median 5.9 years). Secondary outcomes were recurrent IS, cardiovascular death and ICH studied using competing risk analyses. RESULTS High-intensity therapy was initially used by 16.0%, moderate-intensity by 73.8% and low-intensity by 10.2%. Risk of death was lower with high-intensity versus moderate-intensity (adjusted HR (adj.HR) 0.92; 95% CI 0.87 to 0.97; number needed to treat (NNT) 32.0), with moderate-intensity versus low-intensity (adj.HR 0.91; 95% CI 0.87 to 0.95; NNT 27.5) and with high-intensity versus low-intensity (adj.HR 0.83; 95% CI 0.78 to 0.89; NNT 14.6) statin. There was a dose-dependent association of initial statin intensity with a lower probability of recurrent IS (p<0.0001) and cardiovascular death (p<0.0001). The occurrence of ICH was not associated with initial statin intensity (p=0.646). CONCLUSIONS Following IS, more intense initial statin treatment is associated with improved long-term outcomes but not with the risk of ICH. These findings emphasise the importance of high statin intensity shortly after IS.
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Affiliation(s)
- Ville Kytö
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
- Clinical Research Center, Turku University Hospital, Turku, Finland
| | - Julia Åivo
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Turku, Finland
| | - Jori O Ruuskanen
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Turku, Finland
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Khan MO, Shah SA, Mahmood S, Aijaz A, Jatoi NN, Shakil F, Nusrat K, Siddiqui OM, Hameed I. Is endovascular treatment alone as effective and safe as that with preceding intravenous thrombolysis for acute ischemic stroke? A meta-analysis of randomized controlled trials. J Neurosurg Sci 2024; 68:338-347. [PMID: 37389453 DOI: 10.23736/s0390-5616.23.06058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
INTRODUCTION This meta-analysis aimed to evaluate the safety and efficacy of direct endovascular therapy (EVT) and bridging therapy (EVT with preceding intravenous thrombolysis i.e. IVT), in acute anterior circulation, large vessel occlusion stroke. EVIDENCE ACQUISITION Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, Cochrane CENTRAL, SCOPUS and ClinicalTrials.gov. Outcomes of interest were measured by the modified Rankin Scale (mRS), and included: no disability (mRS0), no significant disability despite some symptoms (mRS1), slight disability (mRS2), moderate disability (mRS3), moderately severe disability (mRS4), severe disability (mRS5), mortality (mRS6). Additionally, we inspected patients having excellent outcome, functional independence outcome, and poor outcome, along with successful reperfusion and intracranial hemorrhage. We calculated pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI). EVIDENCE SYNTHESIS A total of seven RCTs involving 2,392 patients were finally included. The chances of achieving successful reperfusion were significantly more with IVT+EVT as compared to EVT alone (RR: 0.97; 95% CI: 0.94, 1.00; P=0.03) (I2=0%). There was no significant difference in the number of patients having outcomes ranging from mRS0 to mRS6, excellent outcome, functional independence, poor outcome or incidence of intracranial hemorrhage, who underwent either EVT alone or IVT+EVT. CONCLUSIONS Additional trials are needed to determine if the absence of significant differences is due to insufficient sample size or if the combination therapy is truly not beneficial.
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Affiliation(s)
- Mohammad O Khan
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syeda A Shah
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Samar Mahmood
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ashnah Aijaz
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Nadia N Jatoi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Firzah Shakil
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Khushboo Nusrat
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Omer M Siddiqui
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ishaque Hameed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan -
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Psychogios K, Theodorou A, Kargiotis O, Safouris A, Velonakis G, Palaiodimou L, Spiliopoulos S, Giannopoulos S, Magoufis G, Tsivgoulis G. Hypoperfusion index ratio and pretreatment with intravenous thrombolysis are independent predictors of good functional outcome in acute ischemic stroke patients with large vessel occlusion treated with acute reperfusion therapies. Neurol Sci 2024:10.1007/s10072-024-07558-w. [PMID: 38761259 DOI: 10.1007/s10072-024-07558-w] [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: 12/27/2023] [Accepted: 04/22/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION We aimed to investigate the performance of several neuroimaging markers provided by perfusion imaging of Acute Ischemic Stroke (AIS) patients with large vessel occlusion (LVO) in order to predict clinical outcomes following reperfusion treatments. METHODS We prospectively evaluated consecutive AIS patients with LVO who were treated with reperfusion therapies, during a six-year period. In order to compare patients with good (mRS scores 0-2) and poor (mRS scores 3-6) functional outcomes, data regarding clinical characteristics, the Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) based on unenhanced computed tomography (CT), CT angiography collateral status and perfusion parameters including ischemic core, hypoperfusion volume, mismatch volume between core and penumbra, Tmax > 10 s volume, CBV index and the Hypoperfusion Index Ratio (HIR) were assessed. RESULTS A total of 84 acute stroke patients with LVO who met all the inclusion criteria were enrolled. In multivariable logistic regression models increasing age (odds ratio [OR]: 0.93; 95%CI: 0.88-0.96, p = 0.001), lower admission National Institute of Health Stroke Scale (NIHSS)-score (OR: 0.88; 95%CI: 0.80-0.95, p = 0.004), pretreatment with intravenous thrombolysis (OR: 3.83; 95%CI: 1.29-12.49, p = 0.019) and HIR (OR:0.36; 95%CI: 0.10-0.95, p = 0.042) were independent predictors of good functional outcome at 3 months. The initial univariable associations between HIR and higher likelihood for symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2) were attenuated in multivariable analyses failing to reach statistical significance. DISCUSSION Our pilot observational study of unselected AIS patients with LVO treated with reperfusion therapies demonstrated that pre-treatment low HIR in perfusion imaging and IVT were associated with better functional outcomes.
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Affiliation(s)
- Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, 18547, Piraeus, Greece
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, 18547, Piraeus, Greece
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Georgios Velonakis
- Second Department of Radiology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Georgios Magoufis
- Second Department of Radiology, Interventional Radiology Unit, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
- Neuroradiology Department, Metropolitan Hospital, 18547, Piraeus, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece.
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
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Bücke P, Jung S, Kaesmacher J, Goeldlin MB, Horvath T, Prange U, Beyeler M, Fischer U, Arnold M, Seiffge DJ, Meinel TR. Intravenous thrombolysis in patients with recent intake of direct oral anticoagulants: A target trial analysis after the liberalization of institutional guidelines. Eur Stroke J 2024:23969873241252751. [PMID: 38738861 DOI: 10.1177/23969873241252751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION This study aimed to report the safety and efficacy of off-label intravenous thrombolysis (IVT) with alteplase after sequentially liberalizing our institutional guidelines allowing IVT for patients under direct oral anticoagulants (DOACs) regardless of plasma levels, time of last intake, and without prior anticoagulation reversal therapy. PATIENTS AND METHODS We utilized the target-trial methodology to emulate hypothetical criteria of a randomized controlled trial in our prospective stroke registry. Consecutive DOAC patients (06/2021-11/2023) otherwise qualifying for IVT were included. Safety and efficacy outcomes (symptomatic intracranial hemorrhage [ICH], any radiological ICH, major bleeding, 90-day mortality, 90-day good functional outcome [mRS 0-2 or return to baseline]) were assessed using inverse-probability-weighted regression-adjustment comparing patients with versus without IVT. RESULTS Ninety eight patients fulfilled the target-trial criteria. IVT was given in 49/98 (50%) patients at a median of 178 (interquartile range 134-285) min after symptom onset with median DOAC plasma level of 77 ng/ml (15 patients had plasma levels > 100 ng/ml; 25/49 [51%] were treated within 12 h after last DOAC ingestion). Endovascular therapy was more frequent in patients without IVT (73% vs 33%). Symptomatic ICH occurred in 0/49 patients receiving IVT and 2/49 patients without IVT (adjusted difference -2.5%; 95% CI -5.9 to 0.8). The rates of any radiological ICH were comparable. Patients receiving IVT were more likely to have good functional outcomes. DISCUSSION AND CONCLUSION After liberalizing our approach for IVT regardless of recent DOAC intake, we did not experience any safety concerns. The association of IVT with better functional outcomes warrants prospective randomized controlled trials.
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Affiliation(s)
- Philipp Bücke
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Simon Jung
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Martina B Goeldlin
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas Horvath
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Ulrike Prange
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Morin Beyeler
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - David J Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas R Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
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7
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Broocks G, Kniep H, McDonough R, Bechstein M, Heitkamp C, Winkelmeier L, Klapproth S, Faizy TD, Schell M, Schön G, Hanning U, Gellißen S, Kemmling A, Papanagiotou P, Fiehler J, Meyer L. Thrombectomy in ischemic stroke patients with large core but minor ischemic changes on non-enhanced computed tomography. Int J Stroke 2024:17474930241249588. [PMID: 38666480 DOI: 10.1177/17474930241249588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
PURPOSE The Alberta Stroke Program Early CT Score (ASPECTS) is regularly used to guide patient selection for mechanical thrombectomy (MT). Similarly, penumbral imaging based on computed tomography perfusion (CTP) may serve as neuroimaging tool to guide treatment. Yet, patients with a large ischemic core on CTP may show only minor ischemic changes resulting in a high ASPECTS. AIM We hypothesized twofold: (1) the treatment effect of vessel recanalization in patients with core volume > 50 mL but ASPECTS ⩾ 6 is not different compared to high ASPECTS patients with core volume < 50 mL, and (2) recanalization is associated with core overestimation. METHODS We conducted an observational study analyzing ischemic stroke patients consecutively treated with MT after triage by multimodal CT. Functional endpoint was the rate of functional independence at Day 90 defined as modified Rankin Scale (mRS) 0-2. Imaging endpoint was core overestimation, which was considered when CTP-derived core was larger than the final infarct volume assessed on follow-up imaging. Recanalization was evaluated with the extended Thrombolysis in Cerebral Infarction (eTICI) scale. Multivariable logistic regression analysis and propensity score matching (PSM) were used to assess the association of recanalization (eTICI ⩾ 2b) with functional outcome and core overestimation. RESULTS Of 630 patients with ASPECTS ⩾ 6, 91 patients (14.4%) had a large ischemic core. Following 1:1 PSM, the treatment effect of recanalization was not different in patients with large core and ASPECTS ⩾ 6 (+ 25.8%, 95% CI: 16.3-35.4, p < 0.001) compared to patients with ASPECTS ⩾ 6 and core volume < 50 mL (+ 14.9%, 95% CI: 5.7-24.1, p = 0.002). Recanalization (aOR: 3.46, 95% CI: 1.85-6.47, p < 0.001) and higher core volume (aOR: 1.03, 95% CI: 1.02-1.04, p < 0.001) were significantly associated with core overestimation. CONCLUSION In patients with ASPECTS ⩾ 6, core volumes did not significantly modify outcomes following recanalization. Reperfusion and higher core volume were significantly associated with core overestimation which may explain the treatment effect of MT for patients with a large ischemic core but minor ischemic changes on non-enhanced CT. DATA ACCESS STATEMENT The data analyzed in this study will be available and shared on reasonable request from any qualified researcher for the purpose of replicating the results after clearance by the local ethics committee.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Räty S, Nguyen TN, Nagel S, Strambo D, Michel P, Herweh C, Qureshi MM, Abdalkader M, Virtanen P, Olive-Gadea M, Ribo M, Psychogios M, Nguyen A, Kuramatsu JB, Haupenthal D, Köhrmann M, Deuschl C, Escolà JK, Demeestere J, Lemmens R, Vandewalle L, Yaghi S, Shu L, Puetz V, Kaiser DP, Kaesmacher J, Mujanovic A, Marterstoc DC, Engelhorn T, Berberich A, Klein P, Haussen DC, Mohammaden MH, Abdelhamid H, Fragata I, Cunha B, Romoli M, Hu W, Song J, Fifi JT, Matsoukas S, Sheth SA, Salazar-Marioni SA, Marto JP, Ramos JN, Miszczuk M, Riegler C, Poli S, Poli K, Jadhav AP, Desai S, Maus V, Kaeder M, Siddiqui AH, Monteiro A, Kokkonen T, Diana F, Masoud HE, Suryadareva N, Mokin M, Thanki S, Ylikotila P, Alpay K, Siegler JE, Linfante I, Dabus G, Yavaghal D, Saini V, Nolte CH, Siebert E, Möhlenbruch MA, Ringleb PA, Nogueira RG, Hanning U, Meyer L, Fischer U, Strbian D. Endovascular Thrombectomy Versus Intravenous Thrombolysis of Posterior Cerebral Artery Occlusion Stroke. J Stroke 2024; 26:290-299. [PMID: 38836276 PMCID: PMC11164587 DOI: 10.5853/jos.2024.00458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/04/2024] [Accepted: 04/17/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. METHODS From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0-1) and independent outcome (mRS 0-2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. RESULTS Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3-P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79-1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05-2.12), sICH (aOR 2.87, 95% CI 1.23-6.72), and mortality (aOR 1.77, 95% CI 1.07-2.95). CONCLUSION Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.
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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 Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Davide Strambo
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Pekka Virtanen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marta Olive-Gadea
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Marc Ribo
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Anh Nguyen
- Department of Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - David Haupenthal
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | | | | | | | | | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Providence, RI, USA
| | - Liqi Shu
- Department of Neurology, Rhode Island Hospital, Providence, RI, USA
| | - 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
| | - Daniel P.O. Kaiser
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen, Erlangen, Germany
| | - Anne Berberich
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Piers Klein
- Department of Radiology, Boston Medical Center, Boston, MA, USA
| | - Diogo C. Haussen
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Hend Abdelhamid
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisbon, Portugal
| | - Bruno Cunha
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jianlon Song
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Johanna T. Fifi
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | | | - Sunil A. Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA
| | | | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - João Nuno Ramos
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Milena Miszczuk
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Sven Poli
- Hertie-Institute for Clinical Brain Research, Tübingen University, Tübingen, Germany
| | - Khouloud Poli
- Hertie-Institute for Clinical Brain Research, Tübingen University, Tübingen, Germany
| | - Ashutosh P. Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Shashvat Desai
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Maximilian Kaeder
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | | | - Andre Monteiro
- Department of Neurosurgery, University of Buffalo, Buffalo, NY, USA
| | - Tatu Kokkonen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Francesco Diana
- Department of Interventional Neuroradiology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Hesham E. Masoud
- Department of Neurology, New York Upstate Medical University, Syracuse, NY, USA
| | - Neil Suryadareva
- Department of Neurology, New York Upstate Medical University, Syracuse, NY, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Shail Thanki
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Pauli Ylikotila
- Department of Neurology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kemal Alpay
- Department of Radiology, Turku University Hospital and University of Turku, Turku, Finland
| | - James E. Siegler
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | | | | | - Dileep Yavaghal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vasu Saini
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christian H. Nolte
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Eberhart Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | | | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raul G. Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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9
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Gory B, Finitsis S, Olivot JM, Richard S, Marnat G, Sibon I, Viguier A, Cognard C, Mazighi M, Chamorro A, Lapergue B, Maïer B. Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction? Ann Neurol 2024; 95:762-773. [PMID: 38148607 DOI: 10.1002/ana.26867] [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: 08/02/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE Recent data have suggested that ineffective tissue reperfusion despite successful angiographic reperfusion was partly responsible for unfavorable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolysis (IVT) use before EVT. To specifically decipher the effect played by IVT before EVT, we compared the clinical and safety outcomes of patients who experienced a complete reperfusion at the end of EVT according to IVT use before EVT. METHODS The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, observational study at 21 centers that perform EVT in France. Patients were included if they had an anterior large vessel occlusion of the intracranial internal carotid artery or middle cerebral artery (M1/M2 segments) and complete reperfusion (expanded Thrombolysis in Cerebral Infarction score = 3) with EVT within 6 hours, between January 2015 and December 2021. The cohort was divided into two groups according to IVT use before EVT, and propensity score matching (PSM) was used to balance the two groups. Primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included favorable outcome (mRS 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Outcomes were estimated with multivariate logistic models adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and time from symptom onset to puncture. RESULTS Among 5,429 patients included in the ETIS registry, 1,093 were included in the study, including 651 patients with complete recanalization treated with IVT before EVT. After PSM, 488 patients treated with IVT before EVT were compared to 337 patients without IVT. In the matched cohort analysis, the IVT+EVT group had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR] = 1.41, 95% confidence interval [CI] = 1.04-1.91, p = 0.023) and higher rates of favorable outcome (61.1% vs 48.7%, aOR = 1.49, 95% CI = 1.02-2.20, p = 0.041) at 90 days compared with the EVT alone group. Rates of symptomatic intracerebral hemorrhage were comparable between both groups (6.0% vs 4.3%, aOR = 1.16, 95% CI = 0.53-2.54, p = 0.709). INTERPRETATION In clinical practice, even after complete angiographic reperfusion by EVT, prior IVT use improves clinical outcomes of patients without increasing bleeding risk. ANN NEUROL 2024;95:762-773.
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Affiliation(s)
- Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
- INSERM U1254, IADI, Université de Lorraine, 54511, Vandoeuvre-les-Nancy, France
| | - Stephanos Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaloniki, Greece
| | - Jean-Marc Olivot
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France
- CIC-P 1433, INSERM U1116, CHRU-Nancy, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Neurology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Alain Viguier
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | | | - Mikael Mazighi
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
- Department of Neurology, Hôpital Lariboisière, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
| | - Angel Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
- Department of Neurology, Hôpital Saint-Joseph, Paris, France
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Castelijns MC, Hageman SHJ, Teraa M, van der Meer MG, Westerink J, Ten Berg J, Visseren FLJ. Generalisability of trials on antithrombotic treatment intensification in patients with cardiovascular disease. Heart 2024; 110:482-490. [PMID: 38182277 DOI: 10.1136/heartjnl-2023-323519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/08/2023] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVE Assessment of generalisability of guideline-informing trials on antithrombotic treatment intensification to real-world patients with cardiovascular disease (CVD). METHODS Inclusion and exclusion criteria of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS), Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management and Avoidance (CHARISMA), Prevention of Cardiovascular events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction (PEGASUS-TIMI) and Dual Antiplatelet Therapy (DAPT) study were applied to coronary artery disease (CAD) and/or peripheral artery disease (PAD) patients from Utrecht Cardiovascular Cohort-Second Manifestations of Arterial Disease (UCC-SMART) to determine real-world eligibility. Eligible and ineligible patients were compared on baseline characteristics, cardiovascular events, major bleeding and mortality. RESULTS Eligibility ranged from 11%-94% for CAD to 75%-90% for patients with PAD. Cardiovascular, bleeding and mortality risks were higher in COMPASS-eligible patients with CAD (rate ratios (RR) 1.98 (95% CI 1.74 to 2.26), 2.02 (95% CI 1.47 to 2.78) and 3.11 (95% CI 2.71 to 3.57), respectively) and CHARISMA-eligible patients (RR 1.51 (95% CI 1.12 to 2.06), 2.25 (95% CI 1.01 to 6.21) and 4.43 (95% CI 2.79 to 7.51), respectively), and lower in COMPASS-eligible patients with PAD (RR 0.45 (95% CI 0.36 to 0.56), 0.29 (95% CI 0.18 to 0.46) and 0.45 (95% CI 0.38 to 0.54), respectively) and DAPT-eligible patients with CAD (RR CVD 0.49 (95% CI 0.34 to 0.69) and mortality 0.67 (95% CI 0.48 to 0.94)) than ineligible patients. After adjustment for trial eligibility criteria, only higher cardiovascular and mortality risks in COMPASS-eligible patients with CAD and lower cardiovascular risks in CHARISMA-eligible and DAPT-eligible patients persisted with CAD. CONCLUSION A large proportion of contemporary CVD patients would be eligible for intensified antithrombotic treatment trials, with mostly similar adjusted event risks to ineligible patients. Trial-based guideline recommendations are largely applicable to real-world patients.
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Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - Jurrien Ten Berg
- Department of Cardiology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Viticchi G, Falsetti L, Altamura C, Di Felice C, Vernieri F, Bartolini M, Silvestrini M. Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review. Rev Neurosci 2024; 0:revneuro-2024-0002. [PMID: 38459676 DOI: 10.1515/revneuro-2024-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Lorenzo Falsetti
- Clinica Medica, Clinical and Molecular Sciences Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Chiara Di Felice
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Marco Bartolini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
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Bala F, Almekhlafi M, Singh N, Alhabli I, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Appireddy R, Moreau F, Phillips S, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar J, Williams H, Field TS, Manosalva A, Siddiqui M, Zafar A, Imoukhoude O, Hunter G, Benali F, Horn M, Hill MD, Shamy M, Sajobi TT, Buck BH, Swartz RH, Menon BK, Poppe AY. Safety and efficacy of tenecteplase versus alteplase in stroke patients with carotid tandem lesions: Results from the AcT trial. Int J Stroke 2024; 19:322-330. [PMID: 37731173 PMCID: PMC10903116 DOI: 10.1177/17474930231205208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Carotid tandem lesions ((TL) ⩾70% stenosis or occlusion) account for 15-20% of acute stroke with large vessel occlusion. AIMS We investigated the safety and efficacy of intravenous tenecteplase (0.25 mg/kg) versus intravenous alteplase (0.9 mg/kg) in patients with carotid TL. METHODS This is a substudy of the alteplase compared with the tenecteplase trial. Patients with ⩾70% stenosis of the extracranial internal carotid artery (ICA) and concomitant occlusion of the intracranial ICA, M1 or M2 segments of the middle cerebral artery on baseline computed tomography angiography (CTA) were included. Primary outcome was 90-day-modified Rankin Scale (mRS) 0-1. Secondary outcomes were mRS 0-2, mortality, and symptomatic ICH (sICH). Angiographic outcomes were successful recanalization (revised Arterial Occlusive Lesion (rAOL) 2b-3) on first and successful reperfusion (eTICI 2b-3) on final angiographic acquisitions. Multivariable mixed-effects logistic regression was performed. RESULTS Among 1577 alteplase versus tenecteplase randomized controlled trial (AcT) patients, 128 (18.8%) had carotid TL. Of these, 93 (72.7%) underwent intravenous thrombolysis plus endovascular thrombectomy (IVT + EVT), while 35 (27.3%) were treated with IVT alone. In the IVT + EVT group, tenecteplase was associated with higher odds of 90-day-mRS 0-1 (46.0% vs. 32.6%, adjusted OR (aOR) 3.21; 95% CI = 1.06-9.71) compared with alteplase. No statistically significant differences in rates of mRS 0-2 (aOR 1.53; 95% CI = 0.51-4.55), initial rAOL 2b-3 (16.3% vs. 28.6%), final eTICI 2b-3 (83.7% vs. 85.7%), and mortality (18.0% vs. 16.3%) were found. SICH only occurred in one patient. There were no differences in outcomes between thrombolytic agents in the IVT-only group. CONCLUSION In patients with carotid TL treated with EVT, intravenous tenecteplase may be associated with similar or better clinical outcomes, similar angiographic reperfusion rates, and safety outcomes as compared with alteplase.
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Affiliation(s)
- Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Yan Deschaintre
- Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | | | | | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - George Medvedev
- The University of British Columbia, Vancouver, BC, Canada
- Fraser Health Authority, New Westminster, BC, Canada
| | - Jennifer Mandzia
- London Health Sciences Centre, Western University, London, ON, Canada
| | - Aleksandra Pikula
- Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Jay Shankar
- University of Manitoba, Winnipeg, MB, Canada
| | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, The University of British Columbia, Vancouver, BC, Canada
| | | | | | - Atif Zafar
- St. Michael’s Hospital, Toronto, ON, Canada
| | | | - Gary Hunter
- University of Saskatchewan, Saskatoon, SK, Canada
| | - Faysal Benali
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Michel Shamy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tolulope T Sajobi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Richard H Swartz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Alexandre Y Poppe
- Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
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Mehrens D, Fabritius MP, Reidler P, Liebig T, Afat S, Ospel JM, Fröhlich MF, Schwarting J, Ricke J, Dimitriadis K, Goyal M, Kunz WG. Cost-effectiveness of endovascular treatment versus best medical management in basilar artery occlusion stroke: A U.S. healthcare perspective. Eur Stroke J 2024; 9:97-104. [PMID: 37905959 PMCID: PMC10916810 DOI: 10.1177/23969873231209616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/08/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION Two recent studies showed clinical benefit for endovascular treatment (EVT) in basilar artery occlusion (BAO) stroke up to 12 h (ATTENTION) and between 6 and 24 h from onset (BAOCHE). Our aim was to investigate the cost-effectiveness of EVT from a U.S. healthcare perspective. MATERIALS AND METHODS Clinical input data were available for both trials, which were analyzed separately. A decision model was built consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes from a healthcare and a societal perspective. Incremental cost-effectiveness ratios (ICER) were calculated, deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed. RESULTS EVT in addition to best medical management (BMM) resulted in additional lifetime costs of $32,063 in the ATTENTION trial and lifetime cost savings of $7690 in the BAOCHE trial (societal perspective). From a healthcare perspective, EVT led to incremental costs and effectiveness of $37,389 and 2.0 QALYs (ATTENTION) as well as $3516 and 1.9 QALYs (BAOCHE), compared to BMM alone. The ICER values were $-4052/QALY (BAOCHE) and $15,867/QALY (ATTENTION) from a societal perspective. In each trial, PSA showed EVT to be cost-effective in most calculations (99.9%) for a willingness-to-pay threshold of $100,000/QALY. Cost of EVT and age at stroke represented the greatest impact on the ICER. DISCUSSION From an economic standpoint with a lifetime horizon, EVT in addition to BMM is estimated to be highly effective and cost-effective in BAO stroke.
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Affiliation(s)
- Dirk Mehrens
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Paul Reidler
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Saif Afat
- Department of Radiology, University of Tübingen, Tübingen, Germany
| | - Johanna M Ospel
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University Hospital of Basel, Basel, Switzerland
| | - Matthias F Fröhlich
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Julian Schwarting
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Konstantinos Dimitriadis
- Institute for Stroke and Dementia Research, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Wolfgang G Kunz
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
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Marnat G, Lapergue B, Gory B, Kyheng M, Labreuche J, Turc G, Olindo S, Sibon I, Caroff J, Smadja D, Chausson N, Clarençon F, Seners P, Bourcier R, Pop R, Olivot JM, Mazighi M, Moulin S, Janot K, Cognard C, Alamowitch S, Gerschenfeld G. Intravenous thrombolysis with tenecteplase versus alteplase combined with endovascular treatment of anterior circulation tandem occlusions: A pooled analysis of ETIS and TETRIS. Eur Stroke J 2024; 9:124-134. [PMID: 37837202 PMCID: PMC10916828 DOI: 10.1177/23969873231206894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Tandem occlusions are a singular large vessel occlusion entity involving specific endovascular and perioperative antithrombotic management. In this context, data on safety and efficacy of prior intravenous thrombolysis (IVT) with tenecteplase is scarce. We aimed to compare IVT with tenecteplase or alteplase in patients with acute tandem occlusions intended for endovascular treatment. PATIENTS AND METHODS A retrospective pooled analysis of two large observational registries (ETIS (Endovascular Treatment of Ischemic Stroke) and TETRIS (Tenecteplase Treatment in Ischemic Stroke)) was performed on consecutive patients presenting with anterior circulation tandem occlusion treated with IVT using either alteplase (ETIS) or tenecteplase (TETRIS) followed by endovascular treatment between January 2015 and June 2022. Sensitivity analyses on atherosclerosis related tandem occlusions and on patient treated with emergent carotid stenting were conducted. Propensity score overlap weighting analyses were performed. RESULTS We analyzed 753 patients: 124 in the tenecteplase and 629 in the alteplase group. The overall odds of favorable outcome (3-month modified Rankin score 0-2) were comparable between both groups (49.4% vs 47.1%; OR = 1.10, 95%CI 0.85-1.41). Early recanalization, final successful recanalization and mortality favored the use of tenecteplase. The occurrence of any intracranial hemorrhage (ICH) was more frequent after tenecteplase use (OR = 2.24; 95%CI 1.75-2.86). However, risks of symptomatic ICH and parenchymal hematoma remained similar. In atherosclerotic tandems, favorable outcome, mortality, parenchymal hematoma, early recanalization, and final successful recanalization favored the tenecteplase group. In the carotid stenting subgroup, PH were less frequent in the tenecteplase group (OR = 0.18; 95%CI 0.05-0.69). CONCLUSION In patients with tandem occlusions, IVT with tenecteplase seemed reasonably safe in particular with increased early recanalization rates. These findings remain preliminary and should be further confirmed in randomized trials.
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Affiliation(s)
- Gaultier Marnat
- Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | | | - Benjamin Gory
- Neuroradiology, Nancy University Hospital, Université de Lorraine, IADI, INSERM U1254, Nancy, France
| | - Maeva Kyheng
- Biostatistics, Lille University Hospital, Lille, France
| | | | - Guillaume Turc
- Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | | | - Igor Sibon
- Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Jildaz Caroff
- Interventional Neuroradiology − NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Didier Smadja
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | - Nicolas Chausson
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | | | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | | | - Raoul Pop
- Neuroradiology, Strasbourg University Hospital, Strasbourg, France
| | | | - Mikael Mazighi
- Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris Cité, INSERM 1144, FHU Neurovasc, Paris, France
| | - Solène Moulin
- Neurology, Stroke Unit; Reims University Hospital, Reims, France
| | - Kevin Janot
- Neuroradiology, Tours University Hospital, Tours, France
| | | | - Sonia Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Gaspard Gerschenfeld
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
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15
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Sui Y, Shi Y, Yang Y, Xiao J, Zhou Y, Zhang S, Qiu Y, Xie Y, Lv Z. Bridging techniques compared with direct endovascular therapy for stroke due to tandem occlusion: A systematic review and meta-analysis. Asian J Surg 2024; 47:1339-1343. [PMID: 38042661 DOI: 10.1016/j.asjsur.2023.11.088] [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: 09/08/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 12/04/2023] Open
Abstract
The superiority of the bridging strategy of intravenous thrombolysis (IVT) plus endovascular therapy (EVT) to EVT alone for the anterior circulation with tandem vascular occlusion (TO) has not been specifically addressed by a single randomized trial. Analysis of 15 studies (n = 1857 patients) revealed that 90 Day good functional outcomes (MRS≤2) were better for bridging therapy (IVT + EVT) than for dEVT (OR:1.39, 95%CI: 1.09-1.79, p = 0.008); 90-day mortality was lower for IVT + EVT than for dEVT (OR: 0.57; 95%CI: 0.40-0.81, p = 0.002) and rates of successful recanalization were higher for IVT + EVT than for dEVT (OR: 1.79, 95%CI: 1.36-2.36, p<0.0001). However, there was no significant difference in the incidence of symptomatic. intracranial hemorrhage (sICH) between groups (OR 0.91, 95%CI 0.64-1.31, p = 0.62).In conclusion, Patients receiving IVT + EVT have a better functional outcome, lower death rate and a higher rate of successful recanalization than those receiving dEVT but there was no difference in sICH risk between the two treatments.
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Affiliation(s)
- Yihang Sui
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Yu Shi
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Yanmei Yang
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Jin Xiao
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Yanru Zhou
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Siyuan Zhang
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Yue Qiu
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Yang Xie
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Zhiyu Lv
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China; Laboratory of Neurological Diseases and Brain Function, Luzhou, Sichuan, 646000, China.
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16
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Luchowski P, Szmygin M, Barton E, Prus K, Szmygin H, Pyra K, Ficek R, Rejdak K. Poor Prestroke Glycemic Control Increases the Rate of Symptomatic Intracranial Hemorrhage after Mechanical Thrombectomy. J Clin Med 2024; 13:1227. [PMID: 38592044 PMCID: PMC10932016 DOI: 10.3390/jcm13051227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Diabetes is a well-established risk factor for acute ischemic stroke (AIS). This study evaluated the impact of prestroke glycemic control in diabetic patients on their 3-month clinical outcome after mechanical thrombectomy (MT). (2) Methods: AIS patients with a premorbid modified Rankin scale (mRS) score of 0-2 who were admitted within 6 h after stroke onset and treated with MT between January 2020 and August 2023 were retrospectively analyzed. The study evaluated the effect of prestroke glycemic control on the stroke severity, reperfusion rate, symptomatic intracranial hemorrhage (sICH) and favorable clinical outcome (modified Rankin scale score 0-2) at 3 months after endovascular treatment. (3) Results: A total of 364 patients were analyzed, with 275 cases of non-diabetes (ND), 66 of well-controlled diabetes (WCD) and 23 of poorly controlled diabetes (PCD). There was no significant difference in the baseline neurological deficit expressed according to the National Institutes of Health Stroke Scale among the three groups. The time from stroke onset to groin puncture was similar in the ND, WCD and PCD groups (median 215 min, 194.5 min and 222.5 min, respectively). There was no significant difference in the favorable 3-month clinical outcomes among these three groups (35.2% of ND patients, 42.4% of WCD patients and 39.1% of PCD patients) or full recovery (12.4% of ND patients, 11.0% of WCD patients and 17.4% of PCD patients). The rate of sICH was significantly higher in the PCD group as compared to the ND and WDP groups (21.7% of PCD patients versus 7.6% of ND patients, p = 0.038, and 6.0% of WCD patients, p = 0.046), but the 3-month mortality did not differ between the three groups (21.8% of ND group, 19.7% of WCD group and 26.1% of PCD group). (4) Conclusions: This study shows that poor prestroke glycemic control in AIS diabetic patients does not change the chance of a good clinical functional outcome after endovascular treatment. However, the increased risk of hemorrhagic complications in this group of patients should be considered.
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Affiliation(s)
- Piotr Luchowski
- Department of Neurology and Neurological Nursing, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Maciej Szmygin
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-954 Lublin, Poland; (M.S.); (K.P.)
| | - Elzbieta Barton
- Department of Neurology and Neurological Nursing, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Katarzyna Prus
- Department of Neurology, Medical University of Lublin, 20-954 Lublin, Poland; (K.P.); (R.F.); (K.R.)
| | - Hanna Szmygin
- Department of Endocrinology, Center of Oncology of the Lublin Region St. Jana z Dukli, 20-090 Lublin, Poland;
| | - Krzysztof Pyra
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-954 Lublin, Poland; (M.S.); (K.P.)
| | - Remigiusz Ficek
- Department of Neurology, Medical University of Lublin, 20-954 Lublin, Poland; (K.P.); (R.F.); (K.R.)
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, 20-954 Lublin, Poland; (K.P.); (R.F.); (K.R.)
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Sagris D, Ntaios G, Milionis H. Beyond antithrombotics: recent advances in pharmacological risk factor management for secondary stroke prevention. J Neurol Neurosurg Psychiatry 2024; 95:264-272. [PMID: 37775267 DOI: 10.1136/jnnp-2022-329149] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
Abstract
Patients with ischaemic stroke represent a diverse group with several cardiovascular risk factors and comorbidities, which classify them as patients at very high risk of stroke recurrence, cardiovascular adverse events or death. In addition to antithrombotic therapy, which is important for secondary stroke prevention in most patients with stroke, cardiovascular risk factor assessment and treatment also contribute significantly to the reduction of mortality and morbidity. Dyslipidaemia, diabetes mellitus and hypertension represent common and important modifiable cardiovascular risk factors among patients with stroke, while early recognition and treatment may have a significant impact on patients' future risk of major cardiovascular events. In recent years, there have been numerous advancements in pharmacological agents aimed at secondary cardiovascular prevention. These innovations, combined with enhanced awareness and interventions targeting adherence and persistence to treatment, as well as lifestyle modifications, have the potential to substantially alleviate the burden of cardiovascular disease, particularly in patients who have experienced ischaemic strokes. This review summarises the evidence on the contemporary advances on pharmacological treatment and future perspectives of secondary stroke prevention beyond antithrombotic treatment.
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Affiliation(s)
- Dimitrios Sagris
- Department of Internal Medicine, University of Thessaly, Faculty of Medicine, Larissa, Greece
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Faculty of Medicine, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
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18
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Havlíček R, Šaňák D, Černík D, Neradová J, Leško N, Gdovinová Z, Köcher M, Cihlář F, Malik J, Fedorko J, Pedowski P, Zapletalová J. Predictors of Good Clinical Outcome After Endovascular Treatment for Acute Ischemic Stroke due to Tandem Lesion in Anterior Circulation: Results from the ASCENT Study. Cardiovasc Intervent Radiol 2024; 47:218-224. [PMID: 38216741 PMCID: PMC10844141 DOI: 10.1007/s00270-023-03649-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024]
Abstract
PURPOSE Endovascular treatment (EVT) of tandem lesion (TL) in anterior circulation (AC) acute ischemic stroke (AIS) represents still a clinical challenge. We aimed to evaluate selected factors related to EVT and assess other possible predictors of good clinical outcome besides the generally known ones. METHODS AIS patients with TL in AC treated with EVT were enrolled in the multicenter retrospective ASCENT study. A good three-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS) and achieved recanalization using the TICI scale. Symptomatic intracerebral hemorrhage (SICH) was assessed using the SITS-MOST criteria. Logistic regression analysis was used for the assessment of possible predictors of mRS 0-2 with adjustment for potential confounders. RESULTS In total, 300 (68.7% males, mean age 67.3 ± 10.2 years) patients with median of admission NIHSS 17 were analyzed. Recanalization (TICI 2b-3) was achieved in 290 (96.7%) patients and 176 (58.7%) had mRS 0-2. Besides the age, admission NIHSS and SICH, admission glycemia (p = 0.005, OR: 0.884) the stent patency within the first 30 days after EVT (p = 0.0003, OR: 0.219), dual antiplatelet therapy (DAPT) started within 12 h after EVT (p < 0.0001, OR: 5.006) and statin therapy started within 24 h after stenting (p < 0.0001, OR: 5.558) were found as other predictors. CONCLUSION Admission glycemia, start of DAPT within 12 h and statin therapy within 24 h after EVT, and stent patency within the first 30 days after EVT were found as other predictors of good three-month clinical outcome in AIS patients treated with EVT for TL.
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Affiliation(s)
- Roman Havlíček
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and University Hospital Olomouc, Olomouc, Czech Republic
- Comprehensive Stroke Center, Department of Neurology, Central Military Hospital Prague, Prague, Czech Republic
| | - Daniel Šaňák
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and University Hospital Olomouc, Olomouc, Czech Republic.
| | - David Černík
- Comprehensive Stroke Center, Department of Neurology, Masaryk Hospital, KZ a.S., Ústí Nad Labem, Czech Republic
| | - Jarmila Neradová
- Comprehensive Stroke Center, Department of Neurology, Masaryk Hospital, KZ a.S., Ústí Nad Labem, Czech Republic
| | - Norbert Leško
- Department of Neurology, P.J. Šafarik University, Faculty of Medicine and University Hospital L. Pasteur Košice, Košice, Slovakia
| | - Zuzana Gdovinová
- Department of Neurology, P.J. Šafarik University, Faculty of Medicine and University Hospital L. Pasteur Košice, Košice, Slovakia
| | - Martin Köcher
- Department of Radiology, Palacký University Medical School and University Hospital Olomouc, Olomouc, Czech Republic
| | - Filip Cihlář
- Department of Radiology, J. E. Purkinje University, Masaryk Hospital, KZ a.S., Ústí Nad Labem, Czech Republic
| | - Jozef Malik
- Department of Radiology, Central Military Hospital Prague, Prague, Czech Republic
| | - Jakub Fedorko
- Department of Radiodiagnostics and Imagine Techniques, P.J. Šafarik University, Faculty of Medicine and University Hospital L. Pasteur Košice, Košice, Slovakia
| | - Piotr Pedowski
- Department of Radiodiagnostics and Imagine Techniques, P.J. Šafarik University, Faculty of Medicine and University Hospital L. Pasteur Košice, Košice, Slovakia
| | - Jana Zapletalová
- Department of Biophysics and Statistics, Palacký University Medical School Olomouc, Olomouc, Czech Republic
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Bao Q, Wu X, Li Y, Chen S, Zhang Q, Yang M, Yang P. Intravenous thrombolysis in acute ischemic stroke patients with pre-stroke disability: A systematic review and meta-analysis. Brain Behav 2024; 14:e3431. [PMID: 38361315 PMCID: PMC10869883 DOI: 10.1002/brb3.3431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT), which is safe and effective, is the first-line therapy for acute ischemic stroke (AIS). However, its benefit for AIS patients with pre-stroke disability (PSD) is controversial. OBJECTIVE We determined the association of PSD with the safety and efficacy of IVT among patients with AIS. METHODS We searched PubMed, Embase, and the Cochrane Library from inception to May 23, 2022. The articles focusing on outcomes of AIS patients with PSD receiving IVT were retrieved. We used the random-effects model to pool outcomes including mortality, 24 h NIHSS improvement, symptomatic intracerebral hemorrhage (sICH), favorable functional outcome (FFO), the favorable outcome, and mortality prevalence. RESULTS Ten studies (including 245,773 participants) that reported the outcomes of AIS patients with PSD undergoing IVT were included. In unadjusted analyses, PSD was associated with mortality (10 studies; odds ratio [OR] 1.739, 95% confidence interval [CI], 1.336-2.407), FFO (7 studies; OR 1.057, 95% CI, 1.015-1.100), 24 h NIHSS improvement (5 studies; OR .840, 95% CI, .819-.917, p = .000), and sICH (9 studies; OR .773, 95% CI, .481-1.243). In adjusted analyses, PSD was associated with mortality (seven studies; ORadj 1.789, 95% CI, 1.413-2.264), FFO (five studies; ORadj 1.087, 95% CI, 1.002-1.179), 24 h NIHSS improvement (five studies; ORadj .837, 95% CI, .799-.876), and sICH (five studies; ORadj .857, 95% CI, .725-1.012). The prevalence of FFO and mortality in patients with pre-stroke modified Rankin Scale scores of 2-5 were 49% (0.42-0.56) and 37% (0.21-0.53), respectively. CONCLUSIONS Patients with PSD undergoing IVT had a higher mortality rate than those without PSD. Meanwhile, PSD was associated with FFO, and there was no significant difference in sICH and 24 h NIHSS improvement. High-quality data are needed to clarify the benefits of administering IVT in these patients.
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Affiliation(s)
- Qiangji Bao
- Department of NeurosurgeryGuang'an People's HospitalGuang'anSichuanChina
| | - Xinting Wu
- Department of AnesthesiaGuang'an People's HospitalGuang'anSichuanChina
| | - Yiming Li
- Graduate SchoolQinghai UniversityXiningQinghaiChina
| | - Shujun Chen
- Graduate SchoolQinghai UniversityXiningQinghaiChina
| | - Qiang Zhang
- Department of NeurosurgeryQinghai Provincial People's HospitalXiningQinghaiChina
| | - Mingfei Yang
- Department of NeurosurgeryQinghai Provincial People's HospitalXiningQinghaiChina
| | - Peng Yang
- Department of NeurosurgeryQinghai Provincial People's HospitalXiningQinghaiChina
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20
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Morsi RZ, Zhang Y, Carrión-Penagos J, Desai H, Tannous E, Kothari S, Khamis A, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Coleman E, Brorson JR, Mendelson S, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular Thrombectomy With or Without Thrombolysis for Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Neurohospitalist 2024; 14:23-33. [PMID: 38235037 PMCID: PMC10790620 DOI: 10.1177/19418744231200046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Background To this date, whether to administer intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for stroke patients still stirs some debate. We aimed to systematically update the evidence from randomized trials comparing EVT alone vs EVT with bridging IVT. Methods We searched MEDLINE, EMBASE, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT with or without IVT in patients presenting with stroke secondary to a large vessel occlusion. We conducted meta-analyses using random-effects models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH), between EVT and EVT with IVT. We assessed risk of bias using the Cochrane risk-of-bias tool and certainty of evidence for each outcome using the GRADE approach. Results Of 11,111 citations, we included 6 studies with a total of 2336 participants. We found low-certainty evidence of possibly a small decrease in the proportion of patients with functional independence (risk difference [RD] -2.0%, 95% CI -5.9% to 2.0%), low-certainty evidence that there is possibly a small increase in mortality (RD 1.0%, 95% CI -2.2% to 4.7%), and moderate-certainty evidence that there is probably a decrease in sICH (RD -1.0%, 95% CI -1.6% to .7%) for patients with EVT alone compared to EVT plus IVT, respectively. Conclusion Low-certainty evidence shows that there is possibly a small decrease in functional independence, low-certainty evidence shows that there is possibly a small increase in mortality, and moderate-certainty evidence that there is probably a decrease in sICH for patients with EVT alone compared to EVT plus IVT.
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Affiliation(s)
- Rami Z. Morsi
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, NY, USA
| | - Sachin Kothari
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Andrea J. Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ammar Tarabichi
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, SD, USA
| | - Sonam Thind
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Elisheva Coleman
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - James R. Brorson
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Scott Mendelson
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | | | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, IL, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
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21
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Charbonnier G, Consoli A, Bonnet L, Biondi A, Vuillier F, Rabenorosoa K, Mendes Pereira V, Moulin T. Telestroke network to robotic telestroke network: How to upgrade regional stroke care to include remote robotics? Digit Health 2024; 10:20552076241254986. [PMID: 38766366 PMCID: PMC11100382 DOI: 10.1177/20552076241254986] [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: 12/21/2023] [Accepted: 04/23/2024] [Indexed: 05/22/2024] Open
Abstract
Objective Selected patients with large vessel occlusion (LVO) strokes can benefit from endovascular therapy (EVT). However, the effectiveness of EVT is largely dependent on how quickly the patient receives treatment. Recent technological developments have led to the first neurointerventional treatments using robotic assistance, opening up the possibility of performing remote stroke interventions. Existing telestroke networks provide acute stroke care, including remote administration of intravenous thrombolysis (IVT). Therefore, the introduction of remote EVT in distant stroke centers requires an adaptation of the existing telestroke networks. The aim of this work was to propose a framework for centers that are potential candidates for telerobotics according to the resources currently available in these centers. Methods In this paper, we highlight the future challenges for including remote robotics in telestroke networks. A literature review provides potential solutions. Results Existing telestroke networks need to determine which centers to prioritize for remote robotic technologies based on objective criteria and cost-effectiveness analysis. Organizational challenges include regional coordination and specific protocols. Technological challenges mainly concern telecommunication networks. Conclusions Specific adaptations will be necessary if regional telestroke networks are to include remote robotics. Some of these can already be put in place, which could greatly help the future implementation of the technology.
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Affiliation(s)
- Guillaume Charbonnier
- CHU Besançon, Interventional Neuroradiology Department, Besançon, France
- CHU Besançon, Neurology Department, Besançon, France
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UMR INSERM 1322, Université de Franche-Comté, Besançon, France
| | - Arturo Consoli
- Interventional Neuroradiology Department, Hôpital Foch, Paris, France
| | - Louise Bonnet
- CHU Besançon, Neurology Department, Besançon, France
| | - Alessandra Biondi
- CHU Besançon, Interventional Neuroradiology Department, Besançon, France
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UMR INSERM 1322, Université de Franche-Comté, Besançon, France
| | - Fabrice Vuillier
- CHU Besançon, Neurology Department, Besançon, France
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UMR INSERM 1322, Université de Franche-Comté, Besançon, France
| | | | - Vitor Mendes Pereira
- St. Michael's Hospital Li Ka Shing Knowledge Institute, RADIS Lab, Toronto, ON, Canada
- Department of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Thierry Moulin
- CHU Besançon, Neurology Department, Besançon, France
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UMR INSERM 1322, Université de Franche-Comté, Besançon, France
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22
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Hyrenbach S, Rode S, Schabet M, Daffertshofer M, Schoser K, Neumaier S, Ringleb PA. Outcome of endovascular stroke therapy in a large mandatory stroke-registry. Neurol Res Pract 2023; 5:67. [PMID: 38124178 PMCID: PMC10734186 DOI: 10.1186/s42466-023-00287-z] [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: 06/01/2023] [Accepted: 09/28/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Endovascular stroke treatment (EST) has become the standard treatment for patients with stroke due to large vessel occlusion, especially in earlier time windows. Only few data from population-based registries on effectiveness of EST have been published. METHODS Baden-Wuerttemberg is the third largest state in Germany in terms of area and population and has a structured stroke concept since 1998 which includes mandatory collection of quality assurance data. In 2018 and 2019, 3820 of 39,168 ischemic stroke patients (9.8%) were treated by EST (age median 78 y, NIHSS median 14). We analyzed the clinical outcome of these patients determined with the modified Rankin Scale (mRS) at discharge from the hospital or with the initiation of palliative therapy using logistic regression analysis with adjustment for the mRS at admission, additive IVT, age, and NIHSS. RESULTS The probability of an excellent clinical outcome (mRS 0 or 1 at discharge) and for a good clinical outcome (mRS 0-2) were significantly higher in EST-patients (odds-ratio (OR) 1.27; 95% confidence interval (95% CI) 1.13-1.43, and OR of 1.15 (95% CI 1.04-1.28). Also, the regression model showed an advantage for EST-patients with less frequent 'decision for palliative care' (OR 0.87; 95% CI 0.78-0.98). Sensitivity analysis adjusting for intracranial vessel occlusion as further factor showed similar results. CONCLUSION Our data suggest that EST can be of benefit also for an area-wide unselected stroke population, in a large German federal state with sometimes long distance to the next thrombectomy center.
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Affiliation(s)
- Sonja Hyrenbach
- Stroke Working Group, Office for Quality Assurance in Hospitals (QiG BW), Stuttgart, Germany
| | - Susanne Rode
- Stroke Working Group, Office for Quality Assurance in Hospitals (QiG BW), Stuttgart, Germany
| | - Martin Schabet
- Stroke Working Group, Office for Quality Assurance in Hospitals (QiG BW), Stuttgart, Germany
| | - Michael Daffertshofer
- Stroke Working Group, Office for Quality Assurance in Hospitals (QiG BW), Stuttgart, Germany
| | - Karin Schoser
- Stroke Working Group, Office for Quality Assurance in Hospitals (QiG BW), Stuttgart, Germany
| | - Stephan Neumaier
- Stroke Working Group, Office for Quality Assurance in Hospitals (QiG BW), Stuttgart, Germany
| | - Peter A Ringleb
- Stroke Working Group, Office for Quality Assurance in Hospitals (QiG BW), Stuttgart, Germany.
- Department of Neurology, Ruprecht Karls University Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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23
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Morsi RZ, Zhang Y, Zhu M, Xie S, Carrión-Penagos J, Desai H, Tannous E, Kothari SA, Khamis A, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Siegler JE, Coleman ER, Mendelson SJ, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular Thrombectomy with or without Bridging Thrombolysis in Acute Ischemic Stroke: A Cost-Effectiveness Analysis. Neuroepidemiology 2023; 58:47-56. [PMID: 38128500 PMCID: PMC10857025 DOI: 10.1159/000535796] [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: 09/14/2023] [Accepted: 12/03/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND There is unclear added benefit of intravenous thrombolysis (IVT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis to assess the cost-effectiveness of comparing EVT with IVT versus EVT alone. METHODS We used a decision tree to examine the short-term costs and outcomes at 90 days after the occurrence of index stroke to compare the cost-effectiveness of EVT alone with EVT plus IVT for patients with stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio. RESULTS The average costs per patient were estimated to be $47,304, $49,510, $59,770, and $76,561 for EVT-only strategy and $55,482, $57,751, $68,314, and $85,611 for EVT with IVT over 90 days, 1 year, 5 years, and 20 years, respectively. The cost saving of EVT-only strategy was driven by the avoided medication costs of IVT (ranging from $8,178 to $9,050). The additional IVT led to a slight decrease in QALY estimate during the 90-day time horizon (loss of 0.002 QALY), but a small gain over 1-year and 5-year time horizons (0.011 and 0.0636 QALY). At a willingness-to-pay threshold of $50,000 per QALY gained, the probabilities of EVT only being cost-effective were 100%, 100%, and 99.3% over 90-day, 1-year, and 5-year time horizons. CONCLUSION Our cost-effectiveness model suggested that EVT only may be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion.
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Affiliation(s)
- Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA,
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Meng Zhu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shitong Xie
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, New York, USA
| | - Sachin A Kothari
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ammar Tarabichi
- DENT Neuroimaging Center, DENT Neurologic Institute, Amherst, New York, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Sonam Thind
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - James E Siegler
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | | | - Scott J Mendelson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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24
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Naldi A, Pracucci G, Cavallo R, Saia V, Boghi A, Lochner P, Casetta I, Sallustio F, Zini A, Fainardi E, Cappellari M, Tassi R, Bracco S, Bigliardi G, Vallone S, Nencini P, Bergui M, Mangiafico S, Toni D. Mechanical thrombectomy for in-hospital stroke: data from the Italian Registry of Endovascular Treatment in Acute Stroke. J Neurointerv Surg 2023; 15:e426-e432. [PMID: 36882319 DOI: 10.1136/jnis-2022-019939] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/25/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND The benefit, safety, and time intervals of mechanical thrombectomy (MT) in patients with in-hospital stroke (IHS) are unclear. We sought to evaluate the outcomes and treatment times for IHS patients compared with out-of-hospital stroke (OHS) patients receiving MT. METHODS We analyzed data from the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) between 2015 and 2019. We compared the functional outcomes (modified Rankin Scale (mRS) scores) at 3 months, recanalization rates, and symptomatic intracranial hemorrhage (sICH) after MT. Time intervals from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were recorded for both groups, as were door-to-imaging and door-to-groin for OHS. A multivariate analysis was performed. RESULTS Of 5619 patients, 406 (7.2%) had IHS. At 3 months, IHS patients had a lower rate of mRS 0-2 (39% vs 48%, P<0.001) and higher mortality (30.1% vs 19.6%, P<0.001). Recanalization rates and sICH were similar. Time intervals (min, median (IQR)) from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were favorable for IHS (60 (34-106) vs 123 (89-188.5); 150 (105-220) vs 220 (168-294); 227 (164-303) vs 293 (230-370); all P<0.001), whereas OHS had lower door-to-imaging and door-to-groin times compared with stroke onset-to-imaging and onset-to-groin for IHS (29 (20-44) vs 60 (34-106), P<0.001; 113 (84-151) vs 150 (105-220); P<0.001). After adjustment, IHS was associated with higher mortality (aOR 1.77, 95% CI 1.33 to 2.35, P<0.001) and a shift towards worse functional outcomes in the ordinal analysis (aOR 1.32, 95% CI 1.06 to 1.66, P=0.015). CONCLUSION Despite favorable time intervals for MT, IHS patients had worse functional outcomes than OHS patients. Delays in IHS management were detected.
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Affiliation(s)
- Andrea Naldi
- Neurology Unit, Ospedale San Giovanni Bosco, Torino, Piemonte, Italy
| | - Giovanni Pracucci
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Roberto Cavallo
- Neurology Unit, Ospedale San Giovanni Bosco, Torino, Piemonte, Italy
| | - Valentina Saia
- Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Andrea Boghi
- Radiology and Neuroradiology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, University of the Saarland, Homburg, Germany
| | - Ilaria Casetta
- Neurology Unit, University Hospital Arcispedale S. Anna, Ferrara, Italy
| | - Fabrizio Sallustio
- Unità di Trattamento Neurovascolare, Ospedale dei Castelli-ASL6, Rome, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Enrico Fainardi
- Dipartimento di Scienze Biomediche, Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi, Florence, Italy
| | - Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rossana Tassi
- Stroke Unit, Ospedale S. Maria Delle Scotte-University Hospital, Siena, Italy
| | - Sandra Bracco
- UO Neurointerventistica, Ospedale S. Maria Delle Scotte-University Hospital, Siena, Italy
| | - Guido Bigliardi
- Neurologia/Stroke Unit, Ospedale Civile di Baggiovara, AOU Modena, Modena, Italy
| | - Stefano Vallone
- Neuroradiologia, Ospedale Civile di Baggiovara, AOU Modena, Modena, Italy
| | - Patrizia Nencini
- Stroke Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Mauro Bergui
- Interventional Neuroradiology Unit, Città della Salute e della Scienza - Molinette, Turin, Italy
| | - Salvatore Mangiafico
- Interventional Neuroradiology Consultant at IRCCS Neuromed, Pozzilli (IS), and Adjunct Professor of Interventional Neuroradiology at Tor Vergata University, Sapienza University and S. Andrea Hospital, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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25
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Worthmann H, Ernst J, Grosse GM. [What is confirmed in the treatment of ischemic stroke]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1143-1153. [PMID: 37947809 DOI: 10.1007/s00108-023-01622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 11/12/2023]
Abstract
Ischemic stroke is one of the leading causes of death worldwide and the most frequent cause of permanent disability in adulthood. The acute treatment of stroke is time-critical and, according to the time is brain principle, it is important to determine as soon as possible whether recanalization treatment that can save the penumbra is possible. Intravenous thrombolysis (IVT) and, if a large vessel occlusion is identified, endovascular treatment (EVT) possibly in combination with IVT, are recommended. Further treatment in a stroke unit is another important component of acute stroke treatment. The best secondary preventive treatment must already be initiated in the acute phase. The cause of stroke guides making decisions on the ideal secondary preventive strategy. The most important etiologies of stroke are cardiac embolism, atherosclerotic macroangiopathy and cerebral microangiopathy (small vessel disease). Less frequent causes are dissections of arteries supplying the brain or vasculitis. In up to 20-30% of all cases, however, no clear etiology can be determined despite intensive investigation of the cause. This means corresponding uncertainty in the optimal secondary prevention that consists in particular of an anticoagulant medication adapted to the etiology, treatment of cardiovascular risk factors and if necessary surgical or interventional desobliterative procedures. This article describes the diagnostic procedure and the evidence-based treatment of ischemic stroke.
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Affiliation(s)
- Hans Worthmann
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland.
| | - Johanna Ernst
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland
| | - Gerrit M Grosse
- Neurologische Klinik mit Klinischer Neurophysiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland
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26
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Vlegels N, Gonzalez-Ortiz F, Knuth NL, Khalifeh N, Gesierich B, Müller F, Müller P, Klein M, Dimitriadis K, Franzmeier N, Liebig T, Duering M, Reidler P, Dichgans M, Karikari TK, Blennow K, Tiedt S. Brain-derived Tau for Monitoring Brain Injury in Acute Ischemic Stroke. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.18.23298728. [PMID: 38014197 PMCID: PMC10680879 DOI: 10.1101/2023.11.18.23298728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The evolution of infarcts varies widely among patients with acute ischemic stroke (IS) and influences treatment decisions. Neuroimaging is not applicable for frequent monitoring and there is no blood-based biomarker to track ongoing brain injury in acute IS. Here, we examined the utility of plasma brain-derived tau (BD-tau) as a biomarker for brain injury in acute IS. We conducted the prospective, observational Precision Medicine in Stroke [PROMISE] study with serial blood sampling upon hospital admission and at days 2, 3, and 7 in patients with acute ischemic stroke (IS) and for comparison, in patients with stroke mimics (SM). We determined the temporal course of plasma BD-tau, its relation to infarct size and admission imaging-based metrics of brain injury, and its value to predict functional outcome. Upon admission (median time-from-onset, 4.4h), BD-tau levels in IS patients correlated with ASPECTS (ρ=-0.21, P<.0001) and were predictive of final infarct volume (ρ=0.26, P<.0001). In contrast to SM patients, BD-tau levels in IS patients increased from admission (median, 2.9 pg/ml [IQR, 1.8-4.8]) to day 2 (median time-from-onset, 22.7h; median BD-tau, 5.0 pg/ml [IQR, 2.6-10.3]; P<.0001). The rate of change of BD-tau from admission to day 2 was significantly associated with collateral supply (R2=0.10, P<.0001) and infarct progression (ρ=0.58, P<.0001). At day 2, BD-tau was predictive of final infarct volume (ρ=0.59, P<.0001) and showed superior value for predicting the 90-day mRS score compared with final infarct volume. In conclusion, in 502 patients with acute IS, plasma BD-tau was associated with imaging-based metrics of brain injury upon admission, increased within the first 24 hours in correlation with infarct progression, and at 24 hours was superior to final infarct volume in predicting 90-day functional outcome. Further research is needed to determine whether BD-tau assessments can inform decision-making in stroke care.
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Affiliation(s)
- Naomi Vlegels
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
| | - Fernando Gonzalez-Ortiz
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Nicoló Luca Knuth
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
| | - Nada Khalifeh
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
| | - Benno Gesierich
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
- Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Franziska Müller
- Department of Radiology, LMU University Hospital, LMU Munich, Germany
| | - Philipp Müller
- Department of Radiology, LMU University Hospital, LMU Munich, Germany
| | - Matthias Klein
- Department of Neurology, LMU University Hospital, LMU Munich, Germany
| | | | - Nicolai Franzmeier
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Germany
| | - Marco Duering
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
- Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Paul Reidler
- Department of Radiology, LMU University Hospital, LMU Munich, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Thomas K Karikari
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
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Le Floch A, Clarençon F, Rouchaud A, Kyheng M, Labreuche J, Sibon I, Boulouis G, Gory B, Richard S, Caroff J, Blanc R, Seners P, Eker OF, Cho TH, Consoli A, Bourcier R, Guillon B, Dargazanli C, Arquizan C, Denier C, Eugene F, Vannier S, Gentric JC, Gauberti M, Naggara O, Rosso C, Turc G, Ozkul-Wermester O, Cognard C, Albucher JF, Timsit S, Bourdain F, Le Bras A, Richter S, Moulin S, Pop R, Heck O, Moreno R, L'Allinec V, Lapergue B, Marnat G. Influence of prior intravenous thrombolysis in patients treated with mechanical thrombectomy for M2 occlusions: insight from the Endovascular Treatment in Ischemic Stroke (ETIS) registry. J Neurointerv Surg 2023; 15:e289-e297. [PMID: 36460462 DOI: 10.1136/jnis-2022-019672] [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: 09/22/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) for patients treated with mechanical thrombectomy (MT) for proximal occlusions has recently been questioned through randomized trials. However, few patients with M2 occlusions were included. We investigated the influence of prior IVT for patients presenting M2 occlusions treated with MT in comparison with MT alone. METHODS We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry, a multicenter observational study. Data from consecutive patients treated with MT for M2 occlusions between January 2015 and January 2022 at 26 comprehensive stroke centers were analyzed. The primary endpoint was 90-day modified Rankin Scale score of 0-2. Outcomes were compared using propensity score approaches. We also performed sensitivity analysis in relevant subgroups of patients. RESULTS Among 1132 patients with M2 occlusions treated with MT, 570 received prior IVT. The two groups were comparable after propensity analysis. The rate of favorable functional outcome was significantly higher in the IVT+MT group compared with the MT alone group (59.8% vs 44.7%; adjusted OR 1.38, 95% CI 1.10 to 1.75, P=0.008). Hemorrhagic and procedural complications were similar in both groups. In sensitivity analysis excluding patients with anticoagulation treatment, favorable recanalization was more frequent in the IVT+MT group (OR 1.37, 95% CI 1.11 to 1.70, P=0.004). CONCLUSIONS In cases of M2 occlusions, prior IVT combined with MT resulted in better functional outcome than MT alone, without increasing the rate of hemorrhagic or procedural complications. These results suggest the benefit of IVT in patients undergoing MT for M2 occlusions.
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Affiliation(s)
- Agathe Le Floch
- Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
| | - Frédéric Clarençon
- Interventional neuroradiology, University Hospital Pitié Salpêtrière, Paris, France
| | - Aymeric Rouchaud
- Interventional neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- CNRS, XLIM, UMR 7252, Université de Limoges, Limoges, Nouvelle-Aquitaine, France
| | - Maeva Kyheng
- Biostatistics, CHU Lille, Lille, Hauts-de-France, France
| | | | - Igor Sibon
- Neurology, CHU de Bordeaux, Bordeaux, France
| | | | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Raphaël Blanc
- Departement of interventional neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | - Omer F Eker
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Tae-Hee Cho
- Neurology, CHU Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Arturo Consoli
- Interventional Neuroradiologie, Hopital Foch, Suresnes, Ile-de-France, France
| | | | - Benoit Guillon
- Stroke unit, CHU Nantes, Nantes, Pays de la Loire, France
| | - Cyril Dargazanli
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, Occitanie, France
| | - Caroline Arquizan
- Neurology, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | | | | | | | | | | | - Olivier Naggara
- Neuroradiology, GHU Paris Pôle Neuro Sainte-Anne, Paris, Île-de-France, France
| | - Charlotte Rosso
- Neurology, Hôpital Universitaire Pitié Salpêtrière, Paris, Île-de-France, France
| | - Guillaume Turc
- Neurology, GHU Paris Pôle Neuro Sainte-Anne, Paris, Île-de-France, France
| | | | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, CHU Toulouse, Toulouse, Occitanie, France
| | | | | | - Frederic Bourdain
- Neurology, Centre Hospitalier de la Cote Basque, Bayonne, Aquitaine, France
| | - Anthony Le Bras
- Department of Radiology, Centre Hospitalier Bretagne Atlantique, Vannes, Bretagne, France
- Neuroradiology, CHU Rennes Service de radiologie et d'imagerie médicale, Rennes, France
| | | | - Solène Moulin
- Neurology, University Hospital Centre Reims, Reims, Champagne-Ardenne, France
| | - Raoul Pop
- Neuroradiolology, CHU Strasbourg, Strasbourg, Alsace, France
| | - Olivier Heck
- Neurology, CHU Grenoble Alpes, Grenoble, Auvergne-Rhone-Alpes, France
| | - Ricardo Moreno
- Department Of Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | | | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
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Nowak M, Karliński M, Śnieżyński M, Pożarowszczyk N, Kurkowska-Jastrzębska I, Członkowska A. High neutrophil-to-lymphocyte ratio (NLR) predicts poor response to intravenous thrombolysis in white Caucasian stroke patients. J Stroke Cerebrovasc Dis 2023; 32:107341. [PMID: 37757584 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107341] [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: 05/22/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVES Our aim was to investigate usefulness of the neutrophil-to-lymphocyte ratio (NLR) for predicting poor response to intravenous rtPA in white Caucasian ischemic stroke patients treated within 4.5 hours from the onset. MATERIALS AND METHODS This retrospective analysis included all consecutive acute ischemic stroke patients (N = 344) treated with rtPA in a tertiary stroke center from 2011 to 2017. NLR was calculated from complete blood counts obtained on admission. The patients were classified into NLR terciles (T1 <1.75, T2<2.97, T3≥2.97). Significant neurological improvement was defined as an 8-point reduction in the NIHSS score or reaching the score of 0 to 1. RESULTS Compared to NLR T1, patients from NLR T3 were significantly older, more often disabled before stroke, and had longer onset-to-needle time. They less often achieved neurological improvement at day 7 (38% vs 59% p=0.002) and had higher 90-day mortality (27% vs 13%, p=0.020), with no differences in neurological improvement at 24 hours, occurrence of sICH and 7-day mortality. Each additional 4 units of NLR decreased unadjusted and adjusted odds for achieving favorable outcome at day 7 (OR 0.65, 95% CI: 0.46-0.92; aOR 0.62, 95% CI: 0.39-1.00), and increased the odds for death at 3 months (OR 1.60, 95% CI: 1.15-2.24; aOR 1.82, 95% CI:1.14-2.92) CONCLUSIONS: High NLR can predict poor response to intravenous rtPA in Caucasian patients with acute ischemic stroke, especially in terms of not achieving significant neurological improvement at day 7 and death at day 90. It encourages attempts to incorporate NLR in already validated scores.
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Affiliation(s)
- Maciej Nowak
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 street, 02-957 Warsaw, Poland
| | - Michał Karliński
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 street, 02-957 Warsaw, Poland.
| | - Maciej Śnieżyński
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 street, 02-957 Warsaw, Poland
| | - Natalia Pożarowszczyk
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 street, 02-957 Warsaw, Poland
| | - Iwona Kurkowska-Jastrzębska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 street, 02-957 Warsaw, Poland
| | - Anna Członkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9 street, 02-957 Warsaw, Poland
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29
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Tsivgoulis G, Palaiodimou L, Stefanou MI, Theodorou A, Kõrv J, Nunes AP, Candelaresi P, Dall'Ora E, Sariaslani P, Provinciali L, Conforto AB, Cidrao AADL, Karapanayiotides T, Ahmed N. Predictors of functional outcome after symptomatic intracranial hemorrhage complicating intravenous thrombolysis: results from the SITS-ISTR. Eur J Neurol 2023; 30:3161-3171. [PMID: 37410547 DOI: 10.1111/ene.15968] [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: 05/20/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND PURPOSE Several risk factors of symptomatic intracerebral hemorrhage (SICH) following intravenous thrombolysis for acute ischaemic stroke have been established. However, potential predictors of good functional outcome post-SICH have been less studied. METHODS Patient data registered in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) from 2005 to 2021 were used. Acute ischaemic stroke patients who developed post intravenous thrombolysis SICH according to the SITS Monitoring Study definition were analyzed to identify predictors of functional outcomes. RESULTS A total of 1679 patients with reported SICH were included, out of which only 2.8% achieved good functional outcome (modified Rankin Scale scores of 0-2), whilst 80.9% died at 3 months. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score and 24-h ΔNIHSS score were independently associated with a lower likelihood of achieving both good and excellent functional outcomes at 3 months. Baseline NIHSS and hematoma location (presence of both SICHs, defined as remote and local SICH concurrently; n = 478) were predictors of early mortality within 24 h. Independent predictors of 3-month mortality were age, baseline NIHSS, 24-h ΔNIHSS, admission serum glucose values and hematoma location (both SICHs). Age, baseline NIHSS score, 24-h ΔNIHSS, hyperlipidemia, prior stroke/transient ischaemic attack, antiplatelet treatment, diastolic blood pressure at admission, glucose values on admission and SICH location (both SICHs) were associated with reduced disability at 3 months (≥1-point reduction across all modified Rankin Scale scores). Patients with remote SICH (n = 219) and local SICH (n = 964) had comparable clinical outcomes, both before and after propensity score matching. CONCLUSIONS Symptomatic intracerebral hemorrhage presents an alarmingly high prevalence of adverse clinical outcomes, with no difference in clinical outcomes between remote and local SICH.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Ana Paiva Nunes
- Stroke Unit, Hospital São José, Lisbon Central University Hospital Center, Lisbon, Portugal
| | | | - Elisa Dall'Ora
- Stroke Unit, Department of Neurology, Bolzano Central Hospital, Bolzano, Italy
| | - Payam Sariaslani
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Leandro Provinciali
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Adriana B Conforto
- Divisão de Neurologia Clínica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | | | - Theodore Karapanayiotides
- Second Department of Neurology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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30
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Checkouri T, Gerschenfeld G, Seners P, Yger M, Ben Hassen W, Chausson N, Olindo S, Caroff J, Marnat G, Clarençon F, Baron JC, Turc G, Alamowitch S. Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase. Stroke 2023; 54:2491-2499. [PMID: 37622385 DOI: 10.1161/strokeaha.123.042691] [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: 01/25/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) with alteplase or tenecteplase before mechanical thrombectomy is the recommended treatment for large-vessel occlusion acute ischemic stroke. There are divergent data on whether these agents differ in terms of early recanalization (ER) rates before mechanical thrombectomy, and little data on their potential differences stratified by ER predictors such as IVT to ER evaluation (IVT-to-EReval) time, occlusion site and thrombus length. METHODS We retrospectively compared the likelihood of ER after IVT with tenecteplase or alteplase in anterior circulation large-vessel occlusion acute ischemic stroke patients from the PREDICT-RECANAL (alteplase) and Tenecteplase Treatment in Ischemic Stroke (tenecteplase) French multicenter registries. ER was defined as a modified Thrombolysis in Cerebral Infarction score 2b-3 on the first angiographic run, or noninvasive vascular imaging in patients with early neurological improvement. Analyses were based on propensity score overlap weighting (leading to exact balance in patient history, stroke characteristics, and initial management between groups) and confirmed with adjusted logistic regression (sensitivity analysis). A stratified analysis based on pre-established ER predictors (IVT-to-EReval time, occlusion site, and thrombus length) was conducted. RESULTS Overall, 1865 patients were included. ER occurred in 156/787 (19.8%) and 199/1078 (18.5%) patients treated with tenecteplase or alteplase, respectively (odds ratio, 1.09 [95% CI, 0.83-1.44]; P=0.52). A differential effect of tenecteplase versus alteplase on the probability of ER according to thrombus length was observed (Pinteraction=0.003), with tenecteplase being associated with higher odds of ER in thrombi >10 mm (odds ratio, 2.43 [95% CI, 1.02-5.81]; P=0.04). There was no differential effect of tenecteplase versus alteplase on the likelihood of ER according to the IVT-to-EReval time (Pinteraction=0.40) or occlusion site (Pinteraction=0.80). CONCLUSIONS Both thrombolytics achieved ER in one-fifth of patients with large-vessel occlusion acute ischemic stroke without significant interaction with IVT-to-EReval time and occlusion site. Compared with alteplase, tenecteplase was associated with a 2-fold higher likelihood of ER in larger thrombi.
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Affiliation(s)
- Thomas Checkouri
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Gaspard Gerschenfeld
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Pierre Seners
- Service de Neurologie, GHU Paris Psychiatrie et Neurosciences, France (P.S.)
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neurologie, Hôpital Fondation Rothschild, Paris, France (P.S.)
| | - Marion Yger
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Wagih Ben Hassen
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, France (W.B.H.)
| | - Nicolas Chausson
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neurologie, Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes (N.C.)
| | | | - Jildaz Caroff
- AP-HP, Service de Neuroradiologie interventionnelle (NEURI), Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France (J.C.)
| | - Gaultier Marnat
- Service de Neuroradiologie diagnostique et interventionnelle (G.M.), France
- CHU de Bordeaux, France (G.M.)
| | - Frédéric Clarençon
- AP-HP, Service de Neuroradiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France (F.C.)
| | - Jean-Claude Baron
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
| | - Guillaume Turc
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
| | - Sonia Alamowitch
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
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31
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Piscopo A, Zanaty M, Dlouhy K. Contemporary Methods for Detection and Intervention of Distal Medium and Small Vessel Occlusions. J Clin Med 2023; 12:6071. [PMID: 37763011 PMCID: PMC10531921 DOI: 10.3390/jcm12186071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The efficacy of using mechanical thrombectomy for proximal large vessel occlusions has been demonstrated in multiple large-scale trials and has further raised the question of its potential utility for distal medium and small vessel occlusions (DMSVOs). Their longer, more tortuous course and smaller corresponding vascular territories render a significant challenge for detection and intervention. The aim of this study is to provide a comprehensive overview of the current imaging and endovascular intervention options for DMSVOs and review the current works in the literature. Compared with traditional computed tomography angiography (CTA) and CT perfusion, recent advances such as multiphase CTA and maps derived from the time-to-maximum parameter coupled with artificial intelligence have demonstrated increased sensitivity for the detection of DMSVOs. Furthermore, newer generations of mini stent retrievers and thromboaspiration devices have allowed for the access and navigation of smaller and more fragile distal arteries. Preliminary studies have suggested that mechanical thrombectomy using this newer generation of devices is both safe and feasible in distal medium-sized vessels, such as M2. However, endovascular intervention utilizing such contemporary methods and devices must be balanced at the discretion of operator experience and favorable vascular anatomy. Further large-scale multicenter clinical trials are warranted to elucidate the indications for as well as to strengthen the safety and efficacy of this approach.
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Affiliation(s)
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA 52242, USA; (A.P.); (K.D.)
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32
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Hankey GJ. Does thrombolysis add value to thrombectomy for acute ischaemic stroke? Lancet 2023; 402:938-939. [PMID: 37640036 DOI: 10.1016/s0140-6736(23)01202-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Graeme J Hankey
- Perron Institute for Neurological and Translational Science, Perth, WA 6009, Australia; Medical School, The University of Western Australia, Perth, WA, Australia.
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33
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Meinel TR, Kaesmacher J, Buetikofer L, Strbian D, Eker OF, Cognard C, Mordasini P, Deppeler S, Mendes Pereira V, Albucher JF, Darcourt J, Bourcier R, Guillon B, Papagiannaki C, Costentin G, Sibolt G, Räty S, Gory B, Richard S, Liman J, Ernst M, Boulanger M, Barbier C, Mechtouff L, Zhang L, Marnat G, Sibon I, Nikoubashman O, Reich A, Consoli A, Weisenburger D, Requena M, Garcia-Tornel A, Saleme S, Moulin S, Pagano P, Saliou G, Carrera E, Janot K, Boix M, Pop R, Della Schiava L, Luft A, Piotin M, Gentric JC, Pikula A, Pfeilschifter W, Arnold M, Siddiqui A, Froehler MT, Furlan AJ, Chapot R, Wiesmann M, Machi P, Diener HC, Kulcsar Z, Bonati L, Bassetti C, Escalard S, Liebeskind D, Saver JL, Fischer U, Gralla J. Time to treatment with bridging intravenous alteplase before endovascular treatment:subanalysis of the randomized controlled SWIFT-DIRECT trial. J Neurointerv Surg 2023; 15:e102-e110. [PMID: 35902234 DOI: 10.1136/jnis-2022-019207] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/13/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND We hypothesized that treatment delays might be an effect modifier regarding risks and benefits of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT). METHODS We used the dataset of the SWIFT-DIRECT trial, which randomized 408 patients to IVT+MT or MT alone. Potential interactions between assignment to IVT+MT and expected time from onset-to-needle (OTN) as well as expected time from door-to-needle (DTN) were included in regression models. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes included mRS shift, mortality, recanalization rates, and (symptomatic) intracranial hemorrhage at 24 hours. RESULTS We included 408 patients (IVT+MT 207, MT 201, median age 72 years (IQR 64-81), 209 (51.2%) female). The expected median OTN and DTN were 142 min and 54 min in the IVT+MT group and 129 min and 51 min in the MT alone group. Overall, there was no significant interaction between OTN and bridging IVT assignment regarding either the functional (adjusted OR (aOR) 0.76, 95% CI 0.45 to 1.30) and safety outcomes or the recanalization rates. Analysis of in-hospital delays showed no significant interaction between DTN and bridging IVT assignment regarding the dichotomized functional outcome (aOR 0.48, 95% CI 0.14 to 1.62), but the shift and mortality analyses suggested a greater benefit of IVT when in-hospital delays were short. CONCLUSIONS We found no evidence that the effect of bridging IVT on functional independence is modified by overall or in-hospital treatment delays. Considering its low power, this subgroup analysis could have missed a clinically important effect, and exploratory analysis of secondary clinical outcomes indicated a potentially favorable effect of IVT with shorter in-hospital delays. Heterogeneity of the IVT effect size before MT should be further analyzed in individual patient meta-analysis of comparable trials. TRIAL REGISTRATION NUMBER URL: https://www. CLINICALTRIALS gov ; Unique identifier: NCT03192332.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Omer Faruk Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Sandro Deppeler
- Neuro Clinical Trial Unit, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Vitor Mendes Pereira
- Division of Neuroradiology and Division of Neurosurgery, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Jean Darcourt
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France
| | - Benoit Guillon
- Department of Neurology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France
| | | | | | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, INSERM U1254, Nancy, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, CHRU-Nancy, Université de Lorraine, INSERM U1116, Nancy, France
| | - Jan Liman
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Gottingen, Germany
| | - Marion Boulanger
- Deparment of Neurology, CHU Caen Normandie, University Caen Normandie, INSERM U1237, Caen, France
| | - Charlotte Barbier
- Department of Neuroradiology, CHU Caen Normandie, University Caen Normandie, INSERM U1237, Caen, France
| | - Laura Mechtouff
- Department of Vascular Neurology, Hospices Civils de Lyon, Lyon, France
| | - Liqun Zhang
- Department of Neurology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Stroke Unit, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
| | - Arturo Consoli
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - David Weisenburger
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain
- Interventional Neuroradiology, Department of Radiology, Hospital Vall d'Heborn, Barcelona, Spain
| | | | - Suzana Saleme
- Department of Neuroradiology, CHU Limoges, Limoges, France
| | | | - Paolo Pagano
- Department of Neuroradiology, CHU Reims, Reims, France
| | - Guillaume Saliou
- Service of Interventional and Diagnostic Radiology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Kevin Janot
- Department of Diagnostic and Interventional Neuroradiology, Tours University Hospital, Tours, France
| | - Marti Boix
- Stroke Unit, Department of Neurosciences, University Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Raoul Pop
- Department of Interventional Neuroradiology, Strasbourg University Hospitals, Strasbourg, France
| | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, Cereneo, Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Michel Piotin
- Department of interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Aleksandra Pikula
- Department of Neurology, University Health Network - Toronto Western Hospital - University of Toronto, Toronto, Ontario, Canada
| | | | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Adnan Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Michael T Froehler
- Vanderbilt Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony J Furlan
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - René Chapot
- Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus, Essen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Paolo Machi
- Department of Neuroradiology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Essen, Germany
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Leo Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Claudio Bassetti
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Escalard
- Department of interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - David Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, UCLA, University of California, Los Angeles, California, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, UCLA, University of California, Los Angeles, California, USA
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Rex NB, McDonough RV, Ospel JM, Kashani N, Sehgal A, Fladt JC, McTaggart RA, Nogueira R, Menon B, Demchuk AM, Tymianski M, Hill MD, Goyal M. CT Perfusion Does Not Modify the Effect of Reperfusion in Patients with Acute Ischemic Stroke Undergoing Endovascular Treatment in the ESCAPE-NA1 Trial. AJNR Am J Neuroradiol 2023; 44:1045-1049. [PMID: 37620153 PMCID: PMC10494951 DOI: 10.3174/ajnr.a7954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/27/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND AND PURPOSE Although reperfusion is associated with improved outcomes in patients with acute ischemic stroke undergoing endovascular treatment, many patients still do poorly. We investigated whether CTP modifies the effect of near-complete reperfusion on clinical outcomes, ie, whether poor clinical outcomes despite near-complete reperfusion can be partly or fully explained by CTP findings. MATERIALS AND METHODS Data are from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial. Admission CTP was processed using RAPID software, generating relative CBF and CBV volume maps at standard thresholds. CTP lesion volumes were compared in patients with-versus-without near-complete reperfusion. Associations between each CTP metric and clinical outcome (90-day mRS) were tested using multivariable logistic regression, adjusted for baseline imaging and clinical variables. Treatment-effect modification was assessed by introducing CTP lesion volume × reperfusion interaction terms in the models. RESULTS CTP lesion volumes and reperfusion status were available in 410/1105 patients. CTP lesion volumes were overall larger in patients without near-complete reperfusion, albeit not always statistically significant. Increased CBF <34%, CBV <34%, CBV <38%, and CBV <42% lesion volumes were associated with worse clinical outcome (ordinal mRS) at 90 days. CTP core lesion volumes did not modify the treatment effect of near-complete recanalization on clinical outcome. CONCLUSIONS CTP did not modify the effect of near-complete reperfusion on clinical outcomes. Thus, CTP cannot explain why some patients with near-complete reperfusion have poor clinical outcomes.
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Affiliation(s)
- N B Rex
- From the Department of Diagnostic Imaging (N.B.R., R.A.M.), Brown University, Providence, Rhode Island
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - R V McDonough
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - J M Ospel
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - N Kashani
- Department of Neurosurgery (N.K.), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - A Sehgal
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - J C Fladt
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Neurology and Stroke Center (J.C.F.), University Hospital Basel, Basel, Switzerland
| | - R A McTaggart
- From the Department of Diagnostic Imaging (N.B.R., R.A.M.), Brown University, Providence, Rhode Island
| | - R Nogueira
- Department of Neurology and Neurosurgery (R.N.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - B Menon
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | | | - M D Hill
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
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Schlemm L, Siebert E, Kleine JF, Riegler C, Bode FJ, Petersens M, Schlemm E, Keil F, Tiedt S, Bohner G, Nolte CH. Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry. Eur Stroke J 2023; 8:610-617. [PMID: 37243508 PMCID: PMC10472953 DOI: 10.1177/23969873231177774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/07/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. METHODS Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. RESULTS 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%-3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%-1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%-2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. CONCLUSION We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.
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Affiliation(s)
- Ludwig Schlemm
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fee Keil
- Institute for Neuroradiology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
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Sahoo A, Abdalkader M, Yamagami H, Huo X, Sun D, Jia B, Weyland CS, Diana F, Kaliaev A, Klein P, Bui J, Kasab SA, de Havenon A, Zaidat OO, Zi W, Yang Q, Michel P, Siegler JE, Yaghi S, Hu W, Nguyen TN. Endovascular Therapy for Acute Stroke: New Evidence and Indications. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:232-242. [PMID: 38025253 PMCID: PMC10657733 DOI: 10.5797/jnet.ra.2023-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/25/2023] [Indexed: 12/01/2023]
Abstract
Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke. In the past few years, endovascular treatment indications have expanded to include patients being treated in the extended window, with large ischemic core infarction, basilar artery occlusion (BAO) thrombectomy, as demonstrated by several randomized clinical trials. Intravenous thrombolysis (IVT) bridging to mechanical thrombectomy has also been studied via several randomized clinical trials, with the overall results indicating that IVT should not be skipped in patients who are candidates for both IVT and EVT. Simplification of neuroimaging protocols in the extended window to permit non-contrast CT, CTA collaterals have also expanded access to mechanical thrombectomy, particularly in regions across the world where access to advanced imaging may not be available. Ongoing study of areas to develop include rescue stenting in patients with failed thrombectomy, medium vessel occlusion thrombectomy, and carotid tandem occlusions. In this narrative review, we summarize recent trials and key data in the treatment of patients with large ischemic core infarct, simplification of neuroimaging protocols for the treatment of patients presenting in the late window, bridging thrombolysis, and BAO EVT evidence. We also summarize areas of ongoing study including medium and distal vessel occlusion.
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Affiliation(s)
- Anurag Sahoo
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Hiroshi Yamagami
- Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Xiaochuan Huo
- Cerebrovascular Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | | - Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
- Vall d'Hebron Research Institute, Barcelona, Spain
| | - Artem Kaliaev
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Piers Klein
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jenny Bui
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sami Al Kasab
- Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Wenjie Zi
- Neurology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Qingwu Yang
- Neurology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Patrik Michel
- Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Shadi Yaghi
- Neurology, Rhode Island Hospital, Brown University School of Medicine, Providence, RI, USA
| | - Wei Hu
- Neurology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Thanh N Nguyen
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
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Wischmann J, Pradhan C, Zimmermann H, Keidel L, Tiedt S, Dimitriadis K, Liebig T, Höglinger G, Kellert L. Impact of ongoing intravenous thrombolysis until completion of endovascular treatment in large vessel occlusion stroke patients. Front Neurol 2023; 14:1231530. [PMID: 37602252 PMCID: PMC10437055 DOI: 10.3389/fneur.2023.1231530] [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: 05/30/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Background Recent studies have implied that ongoing intravenous thrombolysis (IVT) during endovascular treatment (ET) improves functional outcomes in patients who have undergone stroke caused by a large vessel occlusion (LVO). In this study, we investigated the effect of ongoing IVT until completion of ET on procedure duration, first-pass thrombectomy rate, and periprocedural complications. Methods We analyzed patients from the German Stroke Registry-Endovascular Treatment dataset, collected between June 2015 and December 2021. Primary outcomes were modified Rankin Scale (mRS) score after 3 months and achievement of a Thrombolysis In Cerebral Infarction (TICI) score of 2b-3. Secondary parameters included ET duration, first-pass thrombectomy, and periprocedural complications. Results Of the 13,082 patients in the dataset, 1,639 met the study inclusion criteria. A total of n = 317 patients (19.3%) underwent ongoing IVT until completion of ET, while IVT was completed prior to ET in 1,322 patients (80.7%). Ongoing IVT was associated with higher rates of achievement of an mRS score of 0-2 (or a back-to-baseline) after 3 months [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.08-2.17]. Furthermore, ongoing IVT was predictive of achievement of a TICI score of 2b-3 (OR 1.37; 95% CI 1.03-1.83) and of first-pass thrombectomy (OR 2.07; 95% CI 1.51-2.84), while reducing the rate of peri-interventional complications (OR 0.64; 95% CI 0.44-0.94) and reducing ET duration by 24 min [β = -24.35; 95% CI -32.92-(-15.79)]. Conclusion Our findings suggest that ongoing IVT until ET completion has a favorable impact on both clinical and angiographic outcomes, as well as on periprocedural conditions, regardless of the overall time intervals involved. Therefore, rapid ET after IVT should be sought in order to take advantage of the additive effect of ongoing IVT during ET. Future studies should consider IVT timing in the context of ET as a potential confounder and treatment target.
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Affiliation(s)
- Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Linus Keidel
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
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Morsi RZ, Zhang Y, Carrión-Penagos J, Desai H, Tannous E, Kothari S, Khamis AM, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Coleman E, Brorson JR, Mendelson S, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular thrombectomy with or without thrombolysis bridging in patients with acute ischaemic stroke: protocol for a systematic review, meta-analysis of randomised trials and cost-effectiveness analysis. BMJ Open 2023; 13:e064322. [PMID: 37308271 DOI: 10.1136/bmjopen-2022-064322] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Current published guidelines and meta-analyses comparing endovascular thrombectomy (EVT) alone versus EVT with bridging intravenous thrombolysis (IVT) suggest that EVT alone is non-inferior to EVT with bridging thrombolysis in achieving favourable functional outcome. Because of this controversy, we aimed to systematically update the evidence and meta-analyse data from randomised trials comparing EVT alone versus EVT with bridging thrombolysis, and performed an economic evaluation comparing both strategies. METHODS AND ANALYSIS We will conduct a systematic review of randomised controlled trials comparing EVT with or without bridging thrombolysis in patients presenting with large vessel occlusions. We will identify eligible studies by systematically searching the following databases from inception without any language restrictions: MEDLINE (through Ovid), Embase and the Cochrane Library. The following criteria will be used to assess eligibility for inclusion: (1) adult patients ≥18 years old; (2) randomised patients to EVT alone or to EVT with IVT; and (3) measured outcomes, including functional outcomes, at least 90 days after randomisation. Pairs of reviewers will independently screen the identified articles, extract information and assess the risk of bias of eligible studies. We will use the Cochrane Risk-of-Bias tool to evaluate risk of bias. We will also use the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome. We will then perform an economic evaluation based on the extracted data. ETHICS AND DISSEMINATION This systematic review will not require a research ethics approval because no confidential patient data will be used. We will disseminate our findings by publishing the results in a peer-reviewed journal and via presentation at conferences. PROSPERO REGISTRATION NUMBER CRD42022315608.
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Affiliation(s)
- Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, New York, USA
| | - Sachin Kothari
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Assem M Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ammar Tarabichi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Sonam Thind
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Elisheva Coleman
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - James R Brorson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Scott Mendelson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
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Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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Askim T, Hokstad A, Bergh E, Døhl Ø, Ellekjær H, Ihle-Hansen H, Indredavik B, Leer ASM, Lydersen S, Saltvedt I, Seljeseth Y, Thommessen B. Multimodal individualised intervention to prevent functional decline after stroke: protocol of a randomised controlled trial on long-term follow-up after stroke (LAST-long). BMJ Open 2023; 13:e069656. [PMID: 37164457 PMCID: PMC10173970 DOI: 10.1136/bmjopen-2022-069656] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION Multimodal interventions have emerged as new approaches to provide more targeted intervention to reduce functional decline after stroke. Still, the evidence is contradictory. The main objective of the Life After Stroke (LAST)-long trial is to investigate if monthly meetings with a stroke coordinator who offers a multimodal approach to long-term follow-up can prevent functional decline after stroke. METHODS AND ANALYSIS LAST-long is a pragmatic single-blinded, parallel-group randomised controlled trial recruiting participants living in six different municipalities, admitted to four hospitals in Norway. The patients are screened for inclusion and recruited into the trial 3 months after stroke. A total of 300 patients fulfilling the inclusion criteria will be randomised to an intervention group receiving monthly follow-up by a community-based stroke coordinator who identifies the participants' individual risk profile and sets up an action plan based on individual goals, or to a control group receiving standard care. All participants undergo blinded assessments at 6-month, 12-month and 18-month follow-up. Modified Rankin Scale at 18 months is primary outcome. Secondary outcomes are results of blood tests, blood pressure, adherence to secondary prophylaxis, measures of activities of daily living, cognitive function, physical function, physical activity, patient reported outcome measures, caregiver's burden, the use and costs of health services, safety measures and measures of adherence to the intervention. Mixed models will be used to evaluate differences between the intervention and control group for all endpoints across the four time points, with treatment group, time as categorical covariates and their interaction as fixed effects, and patient as random effect. ETHICS AND DISSEMINATION This trial was approved by the Regional Committee of Medical and Health Research Ethics, REC no. 2018/1809. The main results will be published in international peer-reviewed open access scientific journals and to policy-makers and end users in relevant channels. TRIAL REGISTRATION NUMBER ClincalTrials.gov Identifier: NCT03859063, registered on 1 March 2019.
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Affiliation(s)
- Torunn Askim
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Hokstad
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Elin Bergh
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurology, Akershus University Hospital, Lorenskog, Norway
| | - Øystein Døhl
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Finance, Trondheim Municipality, Trondheim, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Bent Indredavik
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Silja Mäkitalo Leer
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Health and Social Services, Trondheim Municipality, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatric Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Yngve Seljeseth
- Department of Medicine, Ålesund Hospital, Helse More og Romsdal HF, Ålesund, Norway
| | - Bente Thommessen
- Department of Neurology, Akershus University Hospital, Lorenskog, Norway
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Schneider AM, Neuhaus AA, Hadley G, Balami JS, Harston GW, DeLuca GC, Buchan AM. Posterior circulation ischaemic stroke diagnosis and management. Clin Med (Lond) 2023; 23:219-227. [PMID: 37236792 PMCID: PMC11046504 DOI: 10.7861/clinmed.2022-0499] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This narrative review provides an overview of the posterior circulation and the clinical features of common posterior circulation stroke (PCS) syndromes in the posterior arterial territories and how to distinguish them from mimics. We outline the hyperacute management of patients with suspected PCS with emphasis on how to identify those who are likely to benefit from intervention based on imaging findings. Finally, we review advances in treatment options, including developments in endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT), and the principles of medical management and indications for neurosurgery. Observational and randomised clinical trial data have been equivocal regarding EVT in PCS, but more recent studies strongly support its efficacy. There have been concomitant advances in imaging of posterior stroke to guide optimal patient selection for thrombectomy. Recent evidence suggests that clinicians should have a heightened suspicion of posterior circulation events with the resultant implementation of timely, evidence-based management.
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Affiliation(s)
| | | | | | - Joyce S Balami
- University of Oxford, Oxford, UK, and consultant stroke physician, Norfolk and Norwich University Teaching Hospital NHS Trust, Norwich, UK
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Abstract
PURPOSE OF REVIEW This review aims to summarize the therapeutic advances and evidence in the medical management of acute ischemic stroke (AIS). Recent evidence comparing the efficacy and safety of tenecteplase (TNK) with alteplase for intravenous thrombolysis (IVT) in AIS will be highlighted. Recent advances and evidence on improving micro-circulation following endovascular procedures and neuroprotection will be reviewed. RECENT FINDINGS A significant number of randomized control studies now support the use of tenecteplase for IVT in AIS. TNK 0.25 mg/kg single bolus is as effective and well tolerated as alteplase 0.9 mg/kg infusion for IVT in AIS. Evidence from randomized control trials (RCTs) has shown effective and well tolerated expansion of the therapeutic window of IVT in the wake-up stroke and up to 9 h after last seen well, using advanced neuroimaging with computed tomography perfusion/MRI. Early evidence suggests that intra-arterial alteplase may help improve microcirculation in patients with large vessel occlusion following successful thrombectomy. However, more trials are required to confirm the results. Similarly, early evidence from a recent RCT showed that remote ischemic conditioning confers potential neuroprotection and improves outcomes in AIS. SUMMARY Converging evidence has demonstrated that for patients with ischemic stroke presenting at under 4.5 h from the onset, TNK is comparable to alteplase. These data along with the practical advantages of TNK have resulted in a shift to replace intravenous TNK as the standard for thrombolysis. Ongoing studies of IVT with TNK are focussed on defining the optimal dose, expanding the time window with multimodal imaging and defining the role of thrombolysis for bridging patients with stroke due to large vessel occlusion.
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Affiliation(s)
- Radhika Nair
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Molad J, Honig A. Current advances in endovascular treatment. Curr Opin Neurol 2023; 36:125-130. [PMID: 36762653 DOI: 10.1097/wco.0000000000001142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Endovascular thrombectomy (EVT) is the most beneficial reperfusion therapy for acute ischemic stroke. Currently, much effort is done to promote trials examining EVT efficacy and safety in various conditions not included in the main randomized controlled trials established the superiority of EVT. This review summarizes the current advances of EVT patients' selection and periprocedural management. RECENT FINDINGS Recent evidence points to beneficial effect of EVT among patients with relatively large ischemic core, premorbid independent nonagenarians and basilar artery occlusion, and suggest that intravenous thrombolysis bridging treatment is associated with better reperfusion rates. Ongoing trials currently examine EVT efficacy and safety in distal vessel occlusions and in large vessel occlusion with low NIHSS. Current evidence also support use of general anaesthesia and avoid postprocedural extremely low or high blood pressure as well as haemodynamic instability. SUMMARY The field of EVT is rapidly evolving. The results of recent trials have dramatically increased the indications for EVT, with many ongoing trials examining further indications.
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Affiliation(s)
- Jeremy Molad
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv
| | - Asaf Honig
- Department of Neurology, Soroka Medical Center, Beer-Sheva, Israel
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Thrombolysis for acute ischaemic stroke: current status and future perspectives. Lancet Neurol 2023; 22:418-429. [PMID: 36907201 DOI: 10.1016/s1474-4422(22)00519-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 03/14/2023]
Abstract
Alteplase is currently the only approved thrombolytic agent for treatment of acute ischaemic stroke, but interest is burgeoning in the development of new thrombolytic agents for systemic reperfusion with an improved safety profile, increased efficacy, and convenient delivery. Tenecteplase has emerged as a potential alternative thrombolytic agent that might be preferred over alteplase because of its ease of administration and reported efficacy in patients with large vessel occlusion. Ongoing research efforts are also looking at potential improvements in recanalisation with the use of adjunct therapies to intravenous thrombolysis. New treatment strategies are also emerging that aim to reduce the risk of vessel reocclusion after intravenous thrombolysis administration. Other research endeavors are looking at the use of intra-arterial thrombolysis after mechanical thrombectomy to induce tissue reperfusion. The growing implementation of mobile stroke units and advanced neuroimaging could boost the number of patients who can receive intravenous thrombolysis by shortening onset-to-treatment times and identifying patients with salvageable penumbra. Continued improvements in this area will be essential to facilitate the ongoing research endeavors and to improve delivery of new interventions.
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Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
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Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Alamowitch S, Turc G, Palaiodimou L, Bivard A, Cameron A, De Marchis GM, Fromm A, Kõrv J, Roaldsen MB, Katsanos AH, Tsivgoulis G. European Stroke Organisation (ESO) expedited recommendation on tenecteplase for acute ischaemic stroke. Eur Stroke J 2023; 8:8-54. [PMID: 37021186 PMCID: PMC10069183 DOI: 10.1177/23969873221150022] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 02/05/2023] Open
Abstract
Within the last year, four randomised-controlled clinical trials (RCTs) have been published comparing intravenous thrombolysis (IVT) with tenecteplase and alteplase in acute ischaemic stroke (AIS) patients with a non-inferiority design for three of them. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted according to ESO standard operating procedure based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. We identified three relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews of the literature and meta-analyses, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert consensus statements were provided if insufficient evidence was available to provide recommendations based on the GRADE approach. For patients with AIS of <4.5 h duration who are eligible for IVT, tenecteplase 0.25 mg/kg can be used as a safe and effective alternative to alteplase 0.9 mg/kg (moderate evidence, strong recommendation). For patients with AIS of <4.5 h duration who are eligible for IVT, we recommend against using tenecteplase at a dose of 0.40 mg/kg (low evidence, strong recommendation). For patients with AIS of <4.5 h duration with prehospital management with a mobile stroke unit who are eligible for IVT, we suggest tenecteplase 0.25 mg/kg over alteplase 0.90 mg/kg (low evidence, weak recommendation). For patients with large vessel occlusion (LVO) AIS of <4.5 h duration who are eligible for IVT, we recommend tenecteplase 0.25 mg/kg over alteplase 0.9 mg/kg (moderate evidence, strong recommendation). For patients with AIS on awakening from sleep or AIS of unknown onset who are selected with non-contrast CT, we recommend against IVT with tenecteplase 0.25 mg/kg (low evidence, strong recommendation). Expert consensus statements are also provided. Tenecteplase 0.25 mg/kg may be favoured over alteplase 0.9 mg/kg for patients with AIS of <4.5 h duration in view of comparable safety and efficacy data and easier administration. For patients with LVO AIS of <4.5 h duration who are IVT-eligible, IVT with tenecteplase 0.25 mg/kg is preferable over skipping IVT before MT, even in the setting of a direct admission to a thrombectomy-capable centre. IVT with tenecteplase 0.25 mg/kg may be a reasonable alternative to alteplase 0.9 mg/kg for patients with AIS on awakening from sleep or AIS of unknown onset and who are IVT-eligible after selection with advanced imaging.
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Affiliation(s)
- Sonia Alamowitch
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, STARE team, iCRIN, Institut du Cerveau, Sorbonne Université, Paris, France
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Paris, France
- INSERM U1266, Paris, France
- FHU NeuroVasc, Paris, France
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, National & Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
| | - Andrew Bivard
- Melbourne Brain Centre, University of Melbourne, Melbourne, Australia
| | - Alan Cameron
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Gian Marco De Marchis
- Department of Neurology & Stroke Center, University Hospital Basel, Switzerland
- Department of Clinical Research, University of Basel, Switzerland
| | - Annette Fromm
- Department of Neurology, Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Melinda B Roaldsen
- Department of Clinical Research, University Hospital of North Norway, Tromsø, Norway
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National & Kapodistrian University of Athens, ‘Attikon’ University Hospital, Athens, Greece
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Endovascular Thrombectomy with or without Intravenous Thrombolysis for Anterior Circulation Large Vessel Occlusion in the Imperial College London Thrombectomy Registry. J Clin Med 2023; 12:jcm12031150. [PMID: 36769801 PMCID: PMC9918289 DOI: 10.3390/jcm12031150] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023] Open
Abstract
Background and purpose. Mechanical thrombectomy (MT) is the standard of care for eligible patients with a large vessel occlusion (LVO) acute ischemic stroke. Among patients undergoing MT there has been uncertainty regarding the role of intravenous thrombolysis (IVT) and previous trials have yielded conflicting results regarding clinical outcomes. We aim to investigate clinical, reperfusion outcomes and safety of MT with or without IVT for ischemic stroke due to anterior circulation LVO. Materials and Methods. This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. The primary outcomes were the rate of in-hospital mortality, symptomatic intracranial haemorrhage and functional independence (mRS 0-2 at 90 days). Results. We enrolled a total of 577 consecutive patients: 161 (27.9%) were treated with MT alone while 416 (72.1%) underwent IVT and MT. Patients with MT who were treated with IVT had lower rates of in-hospital mortality (p = 0.037), higher TICI reperfusion grades (p = 0.007), similar rates of symptomatic intracranial haemorrhage (p = 0.317) and a higher percentage of functional independence mRS (0-2) at 90 days (p = 0.022). Bridging IVT with MT compared to MT alone was independently associated with a favorable post-intervention TICI score (>2b) (OR, 1.716; 95% CI, 1.076-2.735, p = 0.023). Conclusions. Our findings suggest that combined treatment with MT and IVT is safe and results in increased reperfusion rates as compared to MT alone.
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Wagner L, Mohrbach D, Ebinger M, Endres M, Nolte CH, Harmel P, Audebert HJ, Rohmann JL, Siegerink B. Impact of time between thrombolysis and endovascular thrombectomy on outcomes in patients with acute ischaemic stroke. Front Neurol 2022; 13:1018630. [PMID: 36408513 PMCID: PMC9667508 DOI: 10.3389/fneur.2022.1018630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/03/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Benefits of endovascular thrombectomy (ET) after intravenous thrombolysis (IVT) for patients with acute ischaemic stroke (AIS) have been demonstrated, but analyses of the relationship between IVT-ET time delay and functional outcomes among patients receiving both treatments are lacking. METHODS We used data from the "Berlin-Specific Acute Treatment in Ischaemic and haemorrhAgic stroke with Long-term outcome" (B-SPATIAL) registry. Between January 1st, 2016 and December 31st, 2019, we included patients who received both IVT and ET. The primary outcome was the 3-month ordinal modified Rankin scale (mRS) score. The IVT-ET time delay was analyzed in categories and continuously. We used adjusted ordinal logistic regression to estimate common odds ratios (cOR) and 95% confidence intervals (CI). Secondary analyses involved flexible modeling of IVT-ET delay and dichotomous outcomes. RESULTS Of 11,049 patients, 714 who received IVT followed by ET were included. Compared with having an IVT-ET window >120 min (reference), for an IVT-ET window < 30 min, we obtained adjusted cORs for mRS of 0.41 (95% CI: 0.22 to 0.78); and 0.52 (95% CI: 0.33 to 0.82) for 30 to 120 min. Secondary analyses also found protective effects of shorter time delays against "poor" functional outcomes at 3 months. CONCLUSIONS In patients with AIS, shorter IVT-ET intervals were associated with better 3-month functional outcomes. While the time-to-IVT and time-to-ET include the time until medical attention is received, the IVT-ET time delays fall entirely within the domain of medical management and thus might be easier to optimize.
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Affiliation(s)
- Lora Wagner
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Desiree Mohrbach
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH), Charité—Universitätsmedizin Berlin, Berlin, Germany,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Christian H. Nolte
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH), Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Harmel
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J. Audebert
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica L. Rohmann
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Institute of Public Health, Charité—Universitätsmedizin Berlin, Berlin, Germany,*Correspondence: Jessica L. Rohmann
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden University, Leiden, Netherlands
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49
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Bozzani A, Arici V, Ragni F, Sterpetti A, Arbustini E. Intravenous thrombolysis before mechanical thrombectomy in patients with atrial fibrillation. J Neurointerv Surg 2022:jnis-2022-019749. [DOI: 10.1136/jnis-2022-019749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/04/2022]
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50
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Broocks G, Hanning U, Bechstein M, Elsayed S, Faizy TD, Brekenfeld C, Flottmann F, Kniep H, Deb-Chatterji M, Schön G, Thomalla G, Kemmling A, Fiehler J, Meyer L. Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction. JAMA Netw Open 2022; 5:e2235733. [PMID: 36239941 PMCID: PMC9568804 DOI: 10.1001/jamanetworkopen.2022.35733] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Only limited data are available about a potential benefit associated with endovascular treatment (EVT) for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. OBJECTIVE To assess the association of recanalization after EVT with functional outcomes for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included patients enrolled in the German Stroke Registry-Endovascular Treatment with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less who presented between 6 and 24 hours after stroke onset and underwent computed tomography and subsequent EVT between July 1, 2015, and December 31, 2019. MAIN OUTCOMES AND MEASURES The primary end point was a modified Rankin Scale (mRS) score of 3 or less at day 90. The association between recanalization (defined as the occurrence of a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3) and outcome was assessed using logistic regression and inverse probability weighting analysis. INTERVENTION Endovascular treatment. RESULTS Of 5853 patients, 285 (5%; 146 men [51%]; median age, 73 years [IQR, 62-81 years]) met the inclusion criteria and were analyzed. Of these 285 patients, 79 (27.7%) had an mRS score of 3 or less at day 90. The rate of successful recanalization was 75% (215 of 285) and was independently associated with a higher probability of reaching an mRS score of 3 or less (adjusted odds ratio, 4.39; 95% CI, 1.79-10.72; P < .001). In inverse probability weighting analysis, a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3 was associated with a 19% increase (95% CI, 9%-29%; P < .001) in the probability for an mRS score of 3 or more. Multivariable logistic regression analysis suggested a significant treatment benefit associated with vessel recanalization in a time window of up to 17.6 hours and ASPECTS of 3 to 5. The rate of secondary symptomatic intracerebral hemorrhage was 6.3% (18 of 285). CONCLUSIONS AND RELEVANCE In this cohort study reflecting daily clinical practice, vessel recanalization for patients with a low ASPECTS and extended time window was associated with better functional outcomes in a time window up to 17.6 hours and ASPECTS of 3 to 5. The results of this study encourage current randomized clinical trials to enroll patients with a low ASPECTS, even within the extended time window.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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