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Li Q, Abdalkader M, Siegler JE, Yaghi S, Sarraj A, Campbell BCV, Yoo AJ, Zaidat OO, Kaesmacher J, Pujara D, Nogueira RG, Saver JL, Li L, Han Q, Dai Y, Sang H, Yang Q, Nguyen TN, Qiu Z. Mechanical Thrombectomy for Large Ischemic Stroke: A Systematic Review and Meta-analysis. Neurology 2023; 101:e922-e932. [PMID: 37277200 PMCID: PMC10501098 DOI: 10.1212/wnl.0000000000207536] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/04/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is growing evidence for endovascular thrombectomy (EVT) in patients with large ischemic core infarct and large vessel occlusion (LVO). The objective of this study was to compare the efficacy and safety of EVT vs medical management (MM) using a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). METHODS We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to mechanical thrombectomy for large ischemic core from inception until February 10, 2023. The primary outcome was independent ambulation (modified Rankin Scale [mRS] 0-3). Effect sizes were computed as risk ratio (RR) with random-effect or fixed-effect models. The quality of articles was evaluated through the Cochrane risk assessment tool and the Newcastle-Ottawa Scale. This study was registered in PROSPERO (CRD42023396232). RESULTS A total of 5,395 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded by review of the title, abstract, and full text. Finally, 3 RCTs and 10 cohort studies met the inclusion criteria. The RCT analysis showed that EVT improved the 90-day functional outcomes of patients with large ischemic core with high-quality evidence, including independent ambulation (mRS 0-3: RR 1.78, 95% CI 1.28-2.48, p < 0.001) and functional independence (mRS 0-2: RR 2.59, 95% CI 1.89-3.57, p < 0.001), but without significantly increasing the risk of symptomatic intracranial hemorrhage (sICH: RR 1.83, 95% CI 0.95-3.55, p = 0.07) or early mortality (RR 0.95, 95% CI 0.78-1.16, p = 0.61). Analysis of the cohort studies showed that EVT improved functional outcomes of patients without an increase in the incidence in sICH. DISCUSSION This systematic review and meta-analysis indicates that in patients with LVO stroke with a large ischemic core, EVT was associated with improved functional outcomes over MM without increasing sICH risk. The results of ongoing RCTs may provide further insight in this patient population.
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Affiliation(s)
- Qi Li
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Mohamad Abdalkader
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - James E Siegler
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Shadi Yaghi
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Amrou Sarraj
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Bruce C V Campbell
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Albert J Yoo
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Osama O Zaidat
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Johannes Kaesmacher
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Deep Pujara
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Raul G Nogueira
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Jeffrey L Saver
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Lei Li
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Qin Han
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA.
| | - Yi Dai
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Hongfei Sang
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Qingwu Yang
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA
| | - Thanh N Nguyen
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA.
| | - Zhongming Qiu
- From the Department of Neurology (Q.L., Q.H., Y.D., Z.Q.), the 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Radiology (M.A.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Cooper Neurological Institute (J.E.S.), Cooper University Hospital, Camden, NJ; Rhode Island Hospital (S.Y.), Brown University, Providence; University Hospitals Cleveland Medical Center (A.S., D.P.), Case Western Reserve University, OH; Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Texas Stroke Institute (A.J.Y.), Dallas Fort Worth; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; University Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Neurology (J.L.S.), University of California in Los Angeles; Neurology (L.L.), The Second Affiliated Hospital of Harbin Medical University, China; Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Neurology (Q.Y.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqinq, China; and Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA.
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