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Wang T, Jin X, Yang P, Li S, Zhang Q, Shao C, Lu J, Jin X, Chen L. A clinical and computed tomography-based nomogram to predict the outcome in patients with anterior circulation large vessel occlusion after endovascular mechanical thrombectomy. Jpn J Radiol 2024; 42:973-982. [PMID: 38700623 DOI: 10.1007/s11604-024-01583-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/23/2024] [Indexed: 08/31/2024]
Abstract
PURPOSE To explore the positive predictors of the clinical outcome in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion (ACLVO) after endovascular mechanical thrombectomy (EMT) at a 90-day follow-up, and to establish a nomogram model to predict the clinical outcome. MATERIALS AND METHODS AIS patients with ACLVO detected by multimodal Computed Tomography imaging who underwent EMT were collected. Patients were divided into the favorable and the unfavorable groups according to the 90-day modified Rankin Scale (mRS) score. Univariate and multivariate analyses were performed to investigate predictors of the favorable outcome (mRS of 0-2). A nomogram model for predicting the clinical outcome after EMT was drawn, and the receiver operating characteristic (ROC) curve was used to evaluate its predictive value. RESULTS Totally 105 patients including 65 patients in the favorable group and 40 in the unfavorable group were enrolled. Multivariate logistic regression analysis showed that admission National Institute of Health Stroke scale (NIHSS) score [0.858 (95% CI 0.778-0.947)], ACLVO at M2 [20.023 (95% CI 2.204-181.907)] and infarct core (IC) volume [0.943 (95% CI 0.917-0.969)] was positively correlated with favorable outcome. The accuracy of the nomogram model in predicting the outcome was 0.923 (95% CI 0.870-0.976), with a cutoff value of 119.6 points. The area under the ROC curve was 0.848 (95% CI 0.780-0.917; sensitivity, 79.7%; specificity, 90.0%). CONCLUSION A low Admission NIHSS score, ACLVO at M2, and a small IC volume were positive predictors for favorable outcome. The nomogram model may well predict the outcome in AIS patients with ACLVO after EMT.
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Affiliation(s)
- Tiegong Wang
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Xiangyu Jin
- Hainan College of Economics and Business, Haikou, 571127, Hainan, China
| | - Panpan Yang
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Shuai Li
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Qianwen Zhang
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Chengwei Shao
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Xianglan Jin
- Department of Intensive Care Unit, Shanghai Tenth People's Hospital, Tongji University, No. 301 Yanchang Middle Road, Shanghai, 200072, China.
| | - Luguang Chen
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China.
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Singh N, Kenney CC, Butcher KS, Buck B, Barber PA, Field TS, Choi PM, Yu AY, Kleinig T, Appireddy R, Molina CA, Muir KW, Hill MD, Coutts SB. A Randomized Controlled Trial of Tenecteplase Versus Standard of Care for Minor Ischemic Stroke with Proven Occlusion (TEMPO-2): Rational and design of a multicenter, randomized open-label clinical trial. Int J Stroke 2024; 19:817-822. [PMID: 38676572 PMCID: PMC11298112 DOI: 10.1177/17474930241253702] [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] [Indexed: 04/29/2024]
Abstract
BACKGROUND Almost half of acute ischemic stroke patients present with mild symptoms and there are large practice variations in their treatment globally. Individuals with an intracranial occlusion who present with minor stroke are at an increased risk of early neurological deterioration and poor outcomes. Individual patient data meta-analysis in the subgroup of patients with minor deficits showed benefit of alteplase in improving outcomes; however, this benefit has not been seen with intravenous alteplase in published randomized trials. DESIGN TEMPO-2 (A Randomized Controlled Trial of Tenecteplase Versus Standard of Care for Minor Ischemic Stroke With Proven Occlusion) is a prospective, open label with blinded outcome assessment, randomized controlled trial, designed to test the superiority of intravenous tenecteplase (0.25 mg/kg) over nonthrombolytic standard of care, with an estimated sample size of 1274 patients. Adult patients presenting with acute ischemic stroke with the National Institutes of Health Stroke Scale (NIHSS) ⩽ 5 and visible arterial occlusion or perfusion deficit within 12 h of onset are randomized to receive either tenecteplase (0.25 mg/kg) or standard of care. The primary outcome is return to baseline neurological functioning, measured by the modified Rankin scale (mRS) at 90 days. Safety outcomes include death and symptomatic hemorrhage (intra or extra-cranial). Other secondary outcomes include mRS 0-1, mRS 0-2, ordinal shift analysis of the mRS, partial, and full recanalization on follow-up computed tomography angiogram. CONCLUSION Results of this trial will aid in determining whether there is benefit of using tenecteplase (0.25 mg/kg) in treating patients presenting with minor stroke who are at high risk of developing poor outcomes due to presence of an intracranial occlusion. DATA ACCESS STATEMENT Data will be available upon reasonable request.
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Affiliation(s)
- Nishita Singh
- Neurology Division, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Carol C Kenney
- Departments of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Ken S Butcher
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Philip A Barber
- Departments of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Philip M Choi
- Department of Neurosciences, Box Hill Hospital, Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill, VIC, Australia
| | - Amy Yx Yu
- Division of Neurology, Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Keith W Muir
- School of Psychology & Neuroscience, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Michael D Hill
- Departments of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Departments of Medicine and Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shelagh B Coutts
- Departments of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Bae JW, Hyun DK. Endovascular Thrombectomy for Acute Ischemic Stroke : Current Concept in Management. J Korean Neurosurg Soc 2024; 67:397-410. [PMID: 38549263 PMCID: PMC11220414 DOI: 10.3340/jkns.2023.0181] [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: 08/28/2023] [Revised: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 07/04/2024] Open
Abstract
Endovascular thrombectomy (EVT) has been established as the standard of care in the treatment of acute ischemic stroke (AIS) based on landmark randomized controlled trials. Nevertheless, while the strict eligibility of EVT for AIS patients restrict the wide application of EVT, a considerable population still undergoes off-label EVT. Besides, it is important to acknowledge that recanalization is not achieved in approximately 20% of procedures, and more than 50% of patients who undergo EVT still do not experience a favorable outcome. This article reviews the brief history of EVT trials and recent progressions in the treatment of AIS, with focusing on the expanding eligibility criteria, new target for EVT, and the evolution of EVT techniques.
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Affiliation(s)
- Jin Woo Bae
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
| | - Dong Keun Hyun
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
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Qin B, Fu L, Qin H, Liang Y, Qin C, Zhang J, Gao W. Intravenous thrombolysis versus dual antiplatelet therapy for patients with acute minor ischaemic stroke: a systematic review and meta-analysis. Front Pharmacol 2024; 15:1377475. [PMID: 38915465 PMCID: PMC11194400 DOI: 10.3389/fphar.2024.1377475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/24/2024] [Indexed: 06/26/2024] Open
Abstract
Background and purpose The efficacy of intravenous thrombolysis (IVT) in patients with acute minor ischaemic stroke (AMIS) remains unclear. We performed a meta-analysis to compare the efficacy and safety of IVT and dual antiplatelet therapy (DAPT) in patients with AMIS. Methods The Embase, Cochrane Library, PubMed, and Web of Science databases were searched up to 10 October, 2023. Prospective and retrospective studies comparing the clinical outcomes of IVT and DAPT were included. Odds ratios (ORs) and 95% confidence intervals (CIs) for early neurological deterioration (END), excellent and favourable functional outcomes, recurrent ischaemic stroke at 3 months, mortality at 3 months, and symptomatic intracranial haemorrhage (ICH) were pooled using a random-effects model. Results Of the five included studies, 6,340 patients were included. In patients with AMIS, IVT was not significantly associated with excellent and favourable functional outcomes, recurrent ischaemic stroke, or all-cause mortality at 3 months compared to early DAPT. However, a higher risk of symptomatic ICH (OR, 9.31; 95% CI, 3.39-25.57) and END (OR, 2.75; 95% CI, 1.76-4.30) were observed with IVT. Conclusion This meta-analysis indicated that IVT was not superior to DAPT in patients with AMIS, especially in those with nondisabling AIS. However, these findings should be interpreted with caution and have some limitations. Further, well-designed randomised controlled trials are warranted.
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Affiliation(s)
- Bin Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lin Fu
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Huixun Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Yuming Liang
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Cheng Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Jiede Zhang
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Wen Gao
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
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Kumar M, Beyea S, Hu S, Kamal N. Impact of early MRI in ischemic strokes beyond hyper-acute stage to improve patient outcomes, enable early discharge, and realize cost savings. J Stroke Cerebrovasc Dis 2024; 33:107662. [PMID: 38417567 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Early in-patient MR Imaging may assist in identifying stroke etiology, facilitating prompt secondary prevention for ischemic strokes (IS), and potentially enhancing patient outcomes. This study explores the impact of early in patient MRI on IS patient outcomes and healthcare resource use beyond the hyper-acute stage. METHODS In this retrospective registry-based study, 771 admitted transient ischemic attack (TIA) and IS patients at Halifax's QEII Health Centre from 2015 to 2019 underwent in-patient MRI. Cohort was categorized into two groups based on MRI timing: early (within 48 h) and late. Logistic regression and Poisson log-linear models, adjusted for age, sex, stroke severity, acute stroke protocol (ASP) activation, thrombolytic, and thrombectomy, were employed to examine in-hospital, discharge, post-discharge, and healthcare resource utilization outcomes. RESULTS Among the cohort, 39.6 % received early in-patient MRI. ASP activation and TIA were associated with a higher likelihood of receiving early MRI. Early MRI was independently associated with a lower rate of symptomatic changes in neurological status during hospitalization (adjusted odds ratio [OR], 0.42; 95 % confidence interval [CI], 0.20-0.88), higher odds of good functional outcomes at discharge (1.55; 1.11-2.16), lower rate of non-home discharge (0.65; 0.46-0.91), shorter length of stay (regression coefficient, 0.93; 95 % CI, 0.89-0.97), and reduced direct cost of hospitalization (0.77; 0.75-0.79). CONCLUSION Early in-patient MRI utilization in IS patients post-hyper-acute stage was independently associated with improved patient outcomes and decreased healthcare resource utilization, underscoring the potential benefits of early MRI during in-patient management of IS. Further research, including randomized controlled trials, is warranted to validate these findings.
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Affiliation(s)
- Mukesh Kumar
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada.
| | - Steven Beyea
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Canada; IWK Health, Halifax, Canada
| | - Sherry Hu
- Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada; Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
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Sharma A, Pandit AK, Mishra B, Srivastava MVP, Srivastava AK, Vishnu VY, Singh RK. Early neurological deterioration in acute ischemic stroke. Ir J Med Sci 2024; 193:949-955. [PMID: 37561387 DOI: 10.1007/s11845-023-03485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND AND AIMS Early neurological deterioration (END) in acute ischemic stroke (AIS), patients is defined as clinical worsening or recurrence during first 72 h after onset of AIS. We have conducted this study to determine the association between END and functional outcome at 3 months of onset of AIS along with associated risk factors of END in AIS cases. METHODOLOGY This study was conducted after approval of Institute Ethics Committee. Two hundred three consecutive patients were admitted from September 2020 to January 2022 at a tertiary care hospital. One hundred ninety patients were included in the study; patients were divided into two groups: (1) early neurological deterioration (END) and (2) non-early neurological deterioration (non-END). Patients were followed-up either telephonically or in person at approximately 3 months using modified Rankin Scale 0-6. All the clinically significant prognostic markers and p < 0.10 variables were considered significant in univariate analysis; P < 0.05 were considered statistically significant for the multivariate analysis. RESULTS Out of 190 cases included in the cohort 34/190 (17.8%) cases showed END with mean age (56.56 (± 16.6)) and males (20/34 (58.8%)). END was independently associated with high blood glucose at admission (OR = 1.015; P = 0.002; 95%CI = 1.005-1.024) and low serum albumin (OR = 0.208; P = 0.002; 95%CI = 0.077-0.562). Patients with END showed poor functional outcome (mRS > 2) at end of 3 months (32 (94.1%); P < 0.001) and death was also statistically significant (22 (64.7%); P < 0.001) as compared to AIS cases having non-END. CONCLUSION Our study showed END may be associated with poor functional outcome in AIS patients. Higher blood glucose at admission and low serum albumin may be statistically significant causing END. Future prospective cohort with larger sample size may confirm the findings.
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Affiliation(s)
- Archana Sharma
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Awadh Kishor Pandit
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
| | - Biswamohan Mishra
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Achal Kumar Srivastava
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Venugopalan Y Vishnu
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Kumar Singh
- Fellowship Neuroendovascular Therapy, Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Yi L, Li Z, Jiang Y, Jiang Y, Meng X, Li H, Zhao X, Wang Y, Liu L, Wang Y, Gu H. Inflammatory marker profiles and in-hospital neurological deterioration in patients with acute minor ischemic stroke. CNS Neurosci Ther 2024; 30:e14648. [PMID: 38432871 PMCID: PMC10909616 DOI: 10.1111/cns.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/10/2024] [Accepted: 02/10/2024] [Indexed: 03/05/2024] Open
Abstract
AIM The aim of the study was to analyze the association between inflammatory marker profiles and in-hospital neurological deterioration (ND) in acute ischemic stroke (AIS) patients. METHODS Data from patients with minor AIS from the Third China National Stroke Registry were analyzed. Inflammatory cytokine levels within 24 h of admission were measured. The primary outcome was in-hospital ND (an increase in National Institutes of Health Stroke Scale score ≥4 from admission to discharge). Associations were evaluated using odds ratios (ORs) and 95% confidence intervals (CIs) derived from logistic regression models. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were used to evaluate incremental predictive values. RESULTS A total of 4031 patients (1246 women, 30.9%) with a median age of 62 years were included. In-hospital ND occurred in 121 patients (3%). Each standard-deviation increase in interleukin (IL)-6 (OR, 1.17 [95% CI, 1.06-1.31]) and high-sensitivity C-reactive protein (hsCRP) (OR, 1.43 [95% CI, 1.24-1.66]) levels was associated with increased in-hospital ND risk. Incremental predictive values for adding IL-6 (IDI, 0.012; NRI, 0.329) but not hsCRP levels to the conventional risk factors were found. CONCLUSION In minor AIS, hsCRP and IL-6 levels were associated with in-hospital ND, including IL-6 levels in prognostic models improved risk classification.
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Affiliation(s)
- Luo Yi
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Zi‐Xiao Li
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Ying‐Yu Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Xia Meng
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Xing‐Quan Zhao
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yi‐Long Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Li‐Ping Liu
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yong‐Jun Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Hong‐Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
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Arquizan C, Lapergue B, Gory B, Labreuche J, Henon H, Albucher JF, Sibon I, Turc G, Richard S, Nouri N, Cognard C, Marnat G, Naggara O, Di Maria F, Duhamel A, Jovin T, Costalat V. Evaluation of acute mechanical revascularization in minor stroke (NIHSS score ⩽ 5) and large vessel occlusion: The MOSTE multicenter, randomized, clinical trial protocol. Int J Stroke 2023; 18:1255-1259. [PMID: 37350574 DOI: 10.1177/17474930231186039] [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] [Indexed: 06/24/2023]
Abstract
RATIONALE Mechanical thrombectomy (MT) has become the standard of care for patients with acute ischemic stroke secondary to large vessel occlusion (LVO) of the anterior circulation. Conversely, its benefit in patients with National Institutes of Health Stroke Scale (NIHSS) score ⩽ 5 is unproven. AIM To demonstrate the superiority of immediate MT plus best medical treatment (BMT) compared to BMT (with secondary MT in case of deterioration) for increasing the rate of modified Rankin Scale (mRS) score ⩽ 1 at 90 days after minor stroke (NIHSS score ⩽ 5) and anterior circulation LVO. SAMPLE SIZE ESTIMATES To detect an absolute increase of 10% (80% power) in the 90-day mRS score = 0-1 rate in the MT + BMT group, by assuming an mRS score = 0-1 rate of 60% in the BMT group and by considering two interim efficacy/futility analyses (after study completion by 274 and 548 patients), 824 patients must be included by 36 centers in France, Spain, and the USA. METHODS AND DESIGN MOSTE is an international, multicenter, prospectively randomized into two parallel (1:1) arms, open-label, with blinded endpoint trial. Eligibility criteria are diagnosis of acute ischemic stroke within 23 h of last-seen-well, NIHSS score ⩽ 5, and LVO in the anterior circulation (intracranial internal carotid artery, M1 or M1-M2 segment of the middle cerebral artery). STUDY OUTCOMES The primary endpoint is the rate of excellent outcome at day 90 (mRS score = 0-1). Secondary endpoints include the rates of 90-day mRS score = 0-2 and score = 0, NIHSS score change, secondary MT, revascularization and infarct volume growth at 24 h, and quality of life and cognitive function at day 90. Safety outcomes (90-day all-cause mortality, procedural complications, symptomatic intracerebral hemorrhage, and rapid NIHSS score worsening) are recorded. DISCUSSION The MOSTE trial will determine MT efficacy and safety in patients with minor stroke and LVO in the anterior circulation. TRIAL REGISTRATION MOSTE Trial. NCT03796468.
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Affiliation(s)
- Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France
- INSERM U1266, Paris, France
| | | | - Benjamin Gory
- Department of Neuroradiology, Hôpital Central, Nancy, France
- IADI, INSERM U1254, Nancy, France
| | - Julien Labreuche
- Department of Biostatistics, Lille University Hospital, Lille, France
| | - Hilde Henon
- Department of Neurology, Hôpital Salengro, Lille, France
| | | | - Igor Sibon
- Department of Neurology, Hôpital Pellegrin, Bordeaux, France
| | - Guillaume Turc
- INSERM U1266, Paris, France
- Department of Neurology, Hôpital Sainte-Anne, Paris, France
| | | | | | - Christophe Cognard
- Department of Neuroradiology, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Gauthier Marnat
- Department of Neuroradiology, Hôpital Pellegrin, Bordeaux, France
| | - Olivier Naggara
- INSERM U1266, Paris, France
- Department of Neuroradiology, Hôpital Sainte-Anne, Paris, France
| | | | - Alain Duhamel
- Department of Biostatistics, Lille University Hospital, Lille, France
| | - Tudor Jovin
- Cooper Neurological Institute, Camden, NJ, USA
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
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Meng Z, Guo R, Wang T, Bo B, Lin Z, Li Y, Zhao Y, Yu X, Lin DJ, Nachev P, Liang ZP, Li Y. Prediction of Stroke Onset Time With Combined Fast High-Resolution Magnetic Resonance Spectroscopic and Quantitative T 2 Mapping. IEEE Trans Biomed Eng 2023; 70:3147-3155. [PMID: 37200119 DOI: 10.1109/tbme.2023.3277546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The purpose of this work is to develop a multispectral imaging approach that combines fast high-resolution 3D magnetic resonance spectroscopic imaging (MRSI) and fast quantitative T2 mapping to capture the multifactorial biochemical changes within stroke lesions and evaluate its potentials for stroke onset time prediction. METHODS Special imaging sequences combining fast trajectories and sparse sampling were used to obtain whole-brain maps of both neurometabolites (2.0 × 3.0 × 3.0 mm3) and quantitative T2 values (1.9 × 1.9 × 3.0 mm3) within a 9-minute scan. Participants with ischemic stroke at hyperacute (0-24 h, n = 23) or acute (24 h-7d, n = 33) phase were recruited in this study. Lesion N-acetylaspartate (NAA), lactate, choline, creatine, and T2 signals were compared between groups and correlated with patient symptomatic duration. Bayesian regression analyses were employed to compare the predictive models of symptomatic duration using multispectral signals. RESULTS In both groups, increased T2 and lactate levels, as well as decreased NAA and choline levels were detected within the lesion (all p < 0.001). Changes in T2, NAA, choline, and creatine signals were correlated with symptomatic duration for all patients (all p < 0.005). Predictive models of stroke onset time combining signals from MRSI and T2 mapping achieved the best performance (hyperacute: R2 = 0.438; all: R2 = 0.548). CONCLUSION The proposed multispectral imaging approach provides a combination of biomarkers that index early pathological changes after stroke in a clinical-feasible time and improves the assessment of the duration of cerebral infarction. SIGNIFICANCE Developing accurate and efficient neuroimaging techniques to provide sensitive biomarkers for prediction of stroke onset time is of great importance for maximizing the proportion of patients eligible for therapeutic intervention. The proposed method provides a clinically feasible tool for the assessment of symptom onset time post ischemic stroke, which will help guide time-sensitive clinical management.
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Kida H, Sakai K, Sato T, Nakada R, Kitagawa T, Takatsu H, Komatsu T, Sakuta K, Mitsumura H, Iguchi Y. Follow-Up Diffusion-Weighted Image Reveals Delayed Appearance of Ischemic Lesions in Suspected Transient Ischemic Attack. Cureus 2023; 15:e47405. [PMID: 38022071 PMCID: PMC10657785 DOI: 10.7759/cureus.47405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION In patients suspected of transient ischemic attack (TIA), it is not uncommon to find no lesion on the diffusion-weighted image (DWI) on admission but a delayed appearance on the follow-up DWI. METHODS Enrolled patients met the following criteria: (1) MRI performed within 24 hours of onset and seven days after admission; (2) National Institutes of Health Stroke Scale (NIHSS) score ≦4 on admission; (3) pre-stroke modified Rankin scale (mRS) score of 0-1. Patients were divided as follows: no lesion on the first DWI and a new lesion on the second DWI (delayed-specified ischemic stroke; DSIS); and no lesion on either the first or second DWI (well-screened TIA; WSTIA). We compared both groups regarding the clinical background and the outcome at three months. RESULTS We identified 144 cases (male 70%; median age 64 years; DSIS, n=34) between October 2012 and March 2019. DSIS was older (71 vs. 60 years, p=0.006) and had a higher NIHSS score on admission (1 vs. 0, p=0.041), a higher rate of large vessel occlusion (LVO) (17% vs. 2%, p=0.008), and symptom duration over one hour (82% vs. 64%, p=0.041). A favorable outcome mRS score of 0-1 at three months was less frequent in DSIS (85% vs. 96%, p=0.004). Age/10 (OR 1.62, 95%CI 1.17-2.24; p=0.004) and LVO (OR 10.84, 95%CI 1.87-63.06; p=0.008) were independent factors for DSIS. CONCLUSIONS In suspected TIA with age or LVO but no lesion in the initial DWI, the second DWI should be considered to identify the delayed appearance of an ischemic stroke.
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Affiliation(s)
- Hiroyuki Kida
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Kenichiro Sakai
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Takeo Sato
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Ryoji Nakada
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Tomomichi Kitagawa
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Hiroki Takatsu
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Teppei Komatsu
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Kenichi Sakuta
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Hidetaka Mitsumura
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Yasuyuki Iguchi
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
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11
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Cao X, Luo J, Xu B, Xiao Y, Yang T, Sun X, Sui Y. Best medical management versus intravenous thrombolysis for mild non-disabling ischemic stroke: A prospective noninferiority registry study. J Neurol Sci 2023; 451:120706. [PMID: 37379725 DOI: 10.1016/j.jns.2023.120706] [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: 03/12/2022] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES The efficacy and safety of intravenous thrombolysis uncertain in patients with non-disabling mild ischemic stroke. Our aim was to investigate whether best medical management only is noninferior to intravenous thrombolysis plus best medical management therapy for achieving favorable functional outcome at 90 days. MATERIALS AND METHODS In a prospective acute ischemic stroke registry from 2018 through 2020, 314 non-disabling mild ischemic stroke patients received best medical management only and 638 underwent intravenous thrombolysis plus best medical management. The primary outcome was modified Rankin Scale ≤1 at Day 90. The noninferiority margin was -5%. Secondary outcomes of hemorrhagic transformation, early neurologic deterioration and mortality were also evaluated. RESULTS The best medical management only was noninferior to the combined therapy of intravenous thrombolysis and best medical management with regard to the primary outcome (unadjusted risk difference, 1.16%; 95% CI, -3.48% ∼ 5.8%; p = 0.0046 for noninferiority; adjusted risk difference, 3.01%; 95% CI, -3.39% ∼ 9.41%). After propensity score matching, p < 0.0001 for noninferiority. RD, 4.03%; 95% CI, -1.59% ∼ 9.69%. p < 0.0001 for noninferiority. Adjusted RD, 5.23%; 95% CI, -1.88% ∼ 9.97%. The occurrence of hemorrhagic transformation was significantly increased in the group of combination therapy (OR, 4.26; 95% CI, 1.30 to 13.99; p = 0.008), while no significant difference was detected in early neurologic deterioration (OR, 1.11; 95% CI, 0.49-2.52; p = 0.808) and mortality (OR, 0.57; 95% CI, 0.20 to 1.69; p = 0.214) between groups. CONCLUSIONS In the present study, we found the best medical management only was noninferior to the combination therapy of intravenous thrombolysis plus best medical management for non-disabling mild ischemic stroke within 4.5 h after onset. Best medical management may be a treatment of choice for non-disabling mild ischemic stroke patients. Further randomized controlled studies are warranted.
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Affiliation(s)
- Xiaopan Cao
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China; Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China.
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, 223 Handan Road, Yangpu District, Shanghai 200436, China.
| | - Bing Xu
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China
| | - Ying Xiao
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China
| | - Tuo Yang
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China
| | - Xiaohong Sun
- Department of Neurology, The Fourth Affiliated Hospital of China Medical University, 4 Chongshandong Road, Huanggu District, Shenyang 110004, Liaoning, China.
| | - Yi Sui
- Department of Neurology and Neuroscience, Shenyang First People's Hospital, Shenyang Brain Hospital, Shenyang Brain Institute, 67 Qingquan Road, Dadong District, Shenyang 110041, Liaoning, China.
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12
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Lu Z, Xiong Y, Yang K, Gu H, Duan C, Zhao X, Meng X, Wang Y. What predicts large vessel occlusion in mild stroke patients? BMC Neurol 2023; 23:29. [PMID: 36658535 PMCID: PMC9850683 DOI: 10.1186/s12883-022-03020-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/09/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND PURPOSE Mild acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) may benefit from thrombolysis or thrombectomy therapy. However, the predictors for LVO in mild AIS patients have not been extensively explored. We aimed to investigate the predictors for LVO in mild AIS patients. METHODS We collected the data of consecutive AIS patients with a National Institutes of Health Stroke Scale (NIHSS) score ≤ 5 from The Third China National Stroke Registry - a prospective nationwide registry of AIS or transient ischemic attack (TIA) patients in China from August 2015 to March 2018. Patients were divided into LVO and non-LVO group based on the vascular imaging during the hospitalization. Multivariable regression analyses involving clinical characteristics and NIHSS subitems was performed to detect the predictors for LVO. RESULT A total of 7653 mild AIS patients from The Third China National Stroke Registry were included in this study. Among them, 620 patients (8.1%) had LVO. The level of consciousness (adjusted odds ratio, 1.87; 95% confidence interval, 1.08 to 3.23), visual field (adjusted odds ratio, 2.10; 95% confidence interval, 1.43 to 3.06) and sensory (adjusted odds ratio, 0.75; 95% confidence interval, 0.60 to 0.94) were predictors for mild AIS patients with LVO. CONCLUSIONS Impaired LOC, visual field and sensory were independently predictors for LVO in mild stroke patients. Further studies are warranted to test these predictors in prehospital setting and in other population.
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Affiliation(s)
- Zhengzhao Lu
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yunyun Xiong
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.510934.a0000 0005 0398 4153Chinese Institute for Brain Research, Beijing, China
| | - Kaixuan Yang
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Chunmiao Duan
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.24696.3f0000 0004 0369 153XDepartment of Neurology, Beijing Daxing District People’s Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing, China ,grid.510934.a0000 0005 0398 4153Chinese Institute for Brain Research, Beijing, China ,grid.506261.60000 0001 0706 7839Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, 2019RU018, Beijing, China
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13
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Muacevic A, Adler JR, Hanae B, Naima C, Faouzi B. Reasons for Exclusion From Intravenous Thrombolysis in Acute Ischemic Stroke: Experience From a Moroccan Stroke Unit. Cureus 2023; 15:e33248. [PMID: 36741618 PMCID: PMC9890612 DOI: 10.7759/cureus.33248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/03/2023] Open
Abstract
Background and objective The rate of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is still low due to several absolute and relative contraindications, including admission time delay, which remains the main reason for exclusion from thrombolysis. In this study, we aimed to identify reasons for non-thrombolysis at our stroke center. Methods This retrospective study included all patients with a final diagnosis of AIS as per our stroke prospective register from 2014 to 2019. Reasons for non-thrombolysis were analyzed for all AIS and for patients admitted within 4.5 hours from symptom onset. From 2014 to 2016, a non-contrast CT scan was the unique imaging modality used to decide on performing IVT. In 2017, CT angiography was added to the imaging protocol. Results Among 3,562 patients with AIS, 3,365 (94.4%) were excluded from thrombolysis; 2,871 (80.6%) were admitted out of the IVT time window, which represents the main reason for exclusion from thrombolysis. Thrombolysis alert (TA) was triggered for 691 (19.4%) patients, and 197 patients had IVT (which represents 28.5% of TA and 5.5% of all AIS). Minor stroke and rapidly improving symptoms of stroke were also reasons for non-thrombolysis, which explain the high-average initial National Institutes of Health Stoke Scale (NIHSS) score of more than 12 in the thrombolysis group. CT angiography allows for the analysis of the supra-aortic trunks, the circle of Willis, and the collateral status. Therefore, during the period when a CT angiography scan was used, there were more IVTs for minor strokes, rapidly improving strokes, and AIS patients admitted beyond the IVT time window. Conclusions This study highlights the common reasons for exclusion from thrombolysis. Efforts should be undertaken to avoid admission time delays. Also, based on our findings, minor stroke and improving stroke no longer represent absolute contraindications for IVT in AIS.
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14
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Xue R, Zhong W, Zhou Y, He Y, Yan S, Chen Z, Wang J, Gong X, Lou M. Endovascular Treatment for Minor Acute Ischemic Strokes With Large Vessel Occlusion. J Am Heart Assoc 2022; 11:e027326. [PMID: 36533622 PMCID: PMC9798802 DOI: 10.1161/jaha.122.027326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background It remains uncertain whether patients with minor acute ischemic stroke with large vessel occlusion benefit from endovascular treatment (EVT). We aim to evaluate the outcomes of EVT in minor acute ischemic stroke with anterior circulation large vessel occlusion. Methods and Results Based on a nationwide prospective stroke registry, patients with minor acute ischemic stroke with anterior circulation large vessel occlusion within 24 hours of onset were divided into groups receiving standard medical treatment plus EVT or standard medical treatment alone. Primary outcome was excellent functional outcome defined as modified Rankin Scale score 0 to 1 at 90 days. In addition, a multivariable logistic regression model was used to analyze the effect of EVT guided by perfusion imaging. A total of 572 patients with median age 68 years (interquartile range=60-77) and median National Institutes of Health Stroke score 3 (interquartile range =2-4) were identified and 123 patients were treated with standard medical treatment plus EVT. EVT was not associated with excellent functional outcome (unadjusted odds ratio [OR], 0.771 [95% CI, 0.516-1.151]; adjusted OR, 0.793 [95% CI, 0.515-1.219]; P=0.290). However, therapy selection guided by perfusion imaging was a modifier of EVT effect on outcomes, as EVT was significantly associated with excellent functional outcome (60.0% versus 50.8%, unadjusted OR, 1.451 [95% CI, 0.643-3.272]; adjusted OR, 2.849 [95% CI, 1.006-8.067]; P=0.049) but not with symptomatic intracerebral hemorrhage in the imaging-guided group. Conclusions Although functional outcomes in minor acute ischemic stroke caused by anterior circulation large vessel occlusion were not improved from the routine use of EVT, our results suggested that EVT guided by perfusion imaging could be beneficial for those patients. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04487340.
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Affiliation(s)
- Rui Xue
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Wansi Zhong
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Ying Zhou
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Yaode He
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Shenqiang Yan
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Zhicai Chen
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Jianan Wang
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Xiaoxian Gong
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Min Lou
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
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15
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Regenhardt RW, Awad A, Kraft AW, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Etherton MR, Hirsch JA, Rabinov JD, Singhal AB, Rost NS, Stapleton CJ, Leslie-Mazwi TM, Patel AB. Characterizing reasons for stroke thrombectomy ineligibility among potential candidates transferred in a hub-and-spoke network. STROKE (HOBOKEN, N.J.) 2022; 2:e000282. [PMID: 36187724 PMCID: PMC9524427 DOI: 10.1161/svin.121.000282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background Access to endovascular thrombectomy (EVT) is relatively limited. Hub-and-spoke networks seek to transfer appropriate large vessel occlusion (LVO) candidates to EVT-capable hubs. However, some patients are ineligible upon hub arrival, and factors that drive transfer inefficiencies are not well described. We sought to quantify EVT transfer efficiency and identify reasons for EVT ineligibility. Methods Consecutive EVT candidates presenting to 25 spokes from 2018-2020 with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day modified Rankin Scale (mRS) ≤2. Results Among 258 patients, the median age was 70 years (IQR 60-81); 50% were female. 56% were ineligible for EVT after hub arrival. Cited reasons were large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion (5%), sub-occlusive lesion (3%), and goals of care (3%). Late window patients [last known well (LKW) >6 hours] were more likely to be ineligible (67% vs 43%, P<0.0001). EVT ineligible patients were older (73 vs 68 years, p=0.04), had lower NIHSS (10 vs 16, p<0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p<0.0001), longer spoke Telestroke consult-hub arrival time (2.8 vs 2.2 hours, p<0.0001), and received less intravenous thrombolysis (32% vs 45%, p=0.04) compared to eligible patients. EVT ineligibility independently reduced the odds of 90-day mRS≤2 (aOR=0.26, 95%CI=0.12,0.56; p=0.001) when controlling for age, NIHSS, and LKW-hub arrival time. Conclusions Among patients transferred for EVT, there are multiple reasons for ineligibility upon hub arrival, with most excluded for infarct growth and mild symptoms. Understanding factors that drive transfer inefficiencies is important to improve EVT access and outcomes.
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Affiliation(s)
- Robert W Regenhardt
- Neurosurgery, Massachusetts General Hospital
- Neurology, Massachusetts General Hospital
| | - Amine Awad
- Neurology, Massachusetts General Hospital
| | | | | | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
| | | | | | | | | | - James D Rabinov
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
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16
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Sun D, Huo X, Raynald, Wang A, Mo D, Gao F, Ma N, Miao Z. Intra-Arterial Thrombolysis Vs. Mechanical Thrombectomy in Acute Minor Ischemic Stroke Due to Large Vessel Occlusion. Front Neurol 2022; 13:860987. [PMID: 35903125 PMCID: PMC9315389 DOI: 10.3389/fneur.2022.860987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/02/2022] [Indexed: 11/18/2022] Open
Abstract
Background The efficacy and safety of mechanical thrombectomy (MT) in acute large vessel occlusion (LVO) patients with minor stroke (NIHSS ≤ 5) remains undetermined. We aimed to compare the efficacy and safety of intra-arterial thrombolysis (IAT) alone vs. MT for LVO patients with minor stroke. Methods Patients were selected from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment (ANGEL) registry, a prospective multicenter registry study, and divided into MT and IAT alone groups. We compared the outcome measures between the two groups, including 90-day functional outcome evaluated by the modified Rankin Scale (mRS), the final recanalization level, intracranial hemorrhage, and mortality within 90-days by logistic regression models with adjustment. Besides the conventional multivariable analysis, we performed a sensitivity analysis by adjusting the propensity score to confirm our results. The propensity score was derived using a logistic regression model. Results Of the 120 patients, 63 received IAT alone and 57 received MT as the first-line treatment strategy. As compared to MT group, patients in the IAT alone group were associated with a higher chance of 90-day mRS 0-2 [93.7% vs. 71.9%, odds ratio (OR) = 4.75, 95% confidence interval (CI): 1.20–18.80, P = 0.027], a high chance of 90-day mRS 0-3 (96.8% vs. 86.7%, OR = 11.35, 95% CI: 1.93–66.86, P = 0.007), a shorter median time from puncture to recanalization (PTR) (60 min vs. 100 min, β = −63.70, 95% CI: −81.79– −45.61, P < 0.001), a lower chance of any intracranial hemorrhage (ICH) within 48 h (3.2% vs. 19.3%, OR = 0.15, 95% CI: 0.03–0.79, P = 0.025), and a lower chance of mortablity within 90 days (1.6% vs. 9.2%, OR = 0.05, 95% CI: 0.01–0.57, P = 0.016). Similarly, the sensitivity analysis showed the robustness of the primary analysis. Conclusions Compared with MT, IAT may improve 90-day clinical outcomes with decreased ICH rate and mortality in LVO patients with minor stroke.
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Bhole R, Nouer SS, Tolley EA, Turk A, Siddiqui AH, Alexandrov AV, Arthur AS, Mocco J. Predictors of early neurologic deterioration (END) following stroke thrombectomy. J Neurointerv Surg 2022; 15:584-588. [PMID: 35584910 DOI: 10.1136/neurintsurg-2022-018844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/28/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Early neurologic deterioration (END) following ischemic stroke is a serious event and is associated with poor outcomes. However, the incidence and predictors of END after stroke thrombectomy for emergent large vessel occlusion are largely unknown. METHODS The baseline characteristics of patients enrolled in the COMPASS trial (NCT02466893) were analyzed. The primary outcome was worsening of ≥4 National Institutes of Health Stroke Scale (NIHSS) points 24 hours post thrombectomy (4+ END24) and the secondary outcome was deterioration of ≥2 points (2+ END24). RESULTS Among 270 patients, 27 (10%) developed 4+ END24 and 42 (16%) had 2+ END24. Those with 4+ END24 were older (76.4±12.9 vs 70.9±12.9 years; p=0.04), had a higher prevalence of hypertension (96% vs 69%; p=0.003), diabetes (41% vs 27%; p=0.13) and higher pretreatment systolic blood pressure (SBP) (170.4±32.6 vs 157.6±28.1 mmHg; p=0.03). More 4+ END24 patients had failed reperfusion: Thrombolysis in Cerebral Infarction ≤2a (26% vs 8%; p=0.003). In unadjusted analysis, older patients and those with hypertension, diabetes, elevated SBP and failed reperfusion had higher odds of 4+ END24. In adjusted analysis, age increase by 5 years led to an increase in 4+ END24 of 28%, diabetes increased odds of 2.6 and failed reperfusion increased odds of 4.5. In the multivariable analysis for the secondary outcome, age (OR 1.33; 95% CI 1.109 to 1.593), diabetes (OR 2.7; 95% CI 1.247 to 5.764) and failed reperfusion (OR 7.2; 95% CI 0.055 to 0.349) were also significant predictors of 2+ END24. CONCLUSIONS Older patients with acute ischemic stroke who have a history of diabetes or hypertension, with elevated pretreatment SBP and failed reperfusion are at a higher risk of END following stroke thrombectomy for emergent large vessel occlusion.
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Affiliation(s)
- Rohini Bhole
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Simonne S Nouer
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Elizabeth A Tolley
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aquilla Turk
- Neurosurgery, Prisma Health Upstate, Greenville, South Carolina, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | | | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
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18
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Fiedler J, Roubec M, Grubhoffer M, Ostrý S, Procházka V, Langová K, Školoudík D. Emergent microsurgical intervention for acute stroke after mechanical thrombectomy failure: a prospective study. J Neurointerv Surg 2022; 15:439-445. [PMID: 35428739 PMCID: PMC10176344 DOI: 10.1136/neurintsurg-2022-018643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
Abstract
BackgroundDespite all the gains that have been achieved with endovascular mechanical thrombectomy revascularization and intravenous thrombolysis logistics since 2015, there is still a subgroup of patients with salvageable brain tissue for whom persistent emergent large vessel occlusion portends a catastrophic outcome.ObjectiveTo test the safety and efficacy of emergent microsurgical intervention in patients with acute ischemic stroke and symptomatic middle cerebral artery occlusion after failure of mechanical thrombectomy.MethodsA prospective two-center cohort study was conducted. Patients with acute ischemic stroke and middle cerebral artery occlusion for whom recanalization failed at center 1 were randomly allocated to the microsurgical intervention group (MSIG) or control group 1 (CG1). All similar patients at center 2 were included in the control group 2 (CG2) with no surgical intervention. Microsurgical embolectomy and/or extracranial–intracranial bypass was performed in all MSIG patients at center 1.ResultsA total of 47 patients were enrolled in the study: 22 at center 1 (12 allocated to the MSIG and 10 to the CG1) and 25 patients at center 2 (CG2). MSIG group patients showed a better clinical outcome on day 90 after the stroke, where a modified Rankin Scale score of 0–2 was reached in 7 (58.3%) of 12 patients compared with 1/10 (10.0%) patients in the CG1 and 3/12 (12.0%) in the CG2.ConclusionsThis study demonstrated the potential for existing microsurgical techniques to provide good outcomes in 58% of microsurgically treated patients as a third-tier option.
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Affiliation(s)
- Jiří Fiedler
- Department of Neurosurgery, Nemocnice České Budějovice, České Budějovice, Jihočeský, Czech Republic
- Department of Neurosurgery, Univerzita Karlova Lékařská fakulta v Plzni, Plzeň, Plzeňský, Czech Republic
| | - Martin Roubec
- Department of Neurology, University Hospital Ostrava, Ostrava, Moravskoslezský, Czech Republic
- Center for Health Research, Faculty of Medicine, University of Ostrava, Ostrava, Moravskoslezský, Czech Republic
| | - Marek Grubhoffer
- Department of Neurosurgery, Nemocnice České Budějovice, České Budějovice, Jihočeský, Czech Republic
- Department of Neurosurgery, Univerzita Karlova Lékařská fakulta v Plzni, Plzeň, Plzeňský, Czech Republic
| | - Svatopluk Ostrý
- Department of Neurology, Nemocnice České Budějovice, České Budějovice, Jihočeský, Czech Republic
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Praha, Praha, Czech Republic
| | - Václav Procházka
- Department of Radiology, University Hospital Ostrava, Ostrava, Moravskoslezský, Czech Republic
| | - Kateřina Langová
- Department of Biophysics, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Olomoucký, Czech Republic
| | - David Školoudík
- Center for Health Research, Faculty of Medicine, University of Ostrava, Ostrava, Moravskoslezský, Czech Republic
- Department of Radiology, University Hospital Ostrava, Ostrava, Moravskoslezský, Czech Republic
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19
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Shchehlov D, Konotopchyk S, Pastushyn O. Clinical protocol of the ischemic stroke patients treatment. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2021-3(37)-14-56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Today in Ukraine there is no single standardized protocol for the treatment of patients in the acute period of ischemic stroke using modern methods of diagnosis and treatment, which include thrombolytic therapy and endovascular treatment. This protocol was created and implemented in Scientific-practical Center of endovascular neuroradiology, NAMS of Ukraine and is based on the latest recommendations of AHA/ASA and ESO, as well as registers of patients with ischemic stroke. The main purpose of this publication is the creation and implementation of «instructions» for the diagnosis and selection of objective tactics for treating patients in the acute period of ischemic stroke.
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20
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Gwak DS, Choi W, Kwon JA, Shim DH, Kim YW, Hwang YH. Perfusion profile evaluated by severity-weighted multiple Tmax strata predicts early neurological deterioration in minor stroke with large vessel occlusion. J Cereb Blood Flow Metab 2022; 42:329-337. [PMID: 34559021 PMCID: PMC9122513 DOI: 10.1177/0271678x211029165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minor stroke due to large vessel occlusion (LVO) is associated with poor outcomes. Hypoperfused tissue fate may be more accurately predicted by severity-weighted multiple perfusion strata than by a single perfusion threshold. We investigated whether poor perfusion profile evaluated by multiple Tmax strata is associated with early neurological deterioration (END) in patients with minor stroke with LVO. Ninety-four patients with a baseline National Institute of Health Stroke Scale score ≤5 and anterior circulation LVO admitted within 24 hours of onset were included. Tmax strata proportions (Tmax 2-4 s, 4-6 s, 6-8 s, 8-10 s, and >10 s) against the entire hypoperfusion volume (Tmax >2 s) were measured. The perfusion profile was defined as the shift of the distribution of the Tmax strata proportions towards worse hypoperfusion severity compared with that of the entire cohort using the Wilcoxon-Mann-Whitney generalised odds ratio (OR); its performance to predict END was tested. The area under the curve of perfusion profile was 0.785 (95% confidence interval [CI]: 0.691-0.878, p < 0.001). Poor perfusion profile (generalised OR >1.052) was independently associated with END (adjusted OR 13.42 [95% CI: 4.38-41.15], p < 0.001). Thus, perfusion profile with severity-weighted multiple Tmax strata may predict END in minor stroke and LVO.
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Affiliation(s)
- Dong-Seok Gwak
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - WooChan Choi
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jung-A Kwon
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Dong-Hyun Shim
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Yong-Won Kim
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yang-Ha Hwang
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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21
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Abbas R, Herial NA, Naamani KE, Sweid A, Weinberg JH, Habashy KJ, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis. J Stroke Cerebrovasc Dis 2022; 31:106282. [PMID: 34998043 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/24/2021] [Accepted: 12/19/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Groundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6. MATERIALS AND METHODS A retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 - 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not. RESULTS Among 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03). CONCLUSIONS Mechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients' outcomes.
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Affiliation(s)
- Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joshua H Weinberg
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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22
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Volbers B, Gröger R, Engelhorn T, Marsch A, Macha K, Schwab S, Dörfler A, Lang S, Kallmünzer B. Acute Stroke With Large Vessel Occlusion and Minor Clinical Deficits: Prognostic Factors and Therapeutic Implications. Front Neurol 2021; 12:736795. [PMID: 34744977 PMCID: PMC8568768 DOI: 10.3389/fneur.2021.736795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/16/2021] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: The optimal acute management of patients with large vessel occlusion (LVO) and minor clinical deficits on admission [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] remains to be elucidated. The aim of the present study was to investigate the prognostic factors and therapeutic management of those patients. Methods: In this retrospective cohort study, we investigated (1) all patients with acute ischemic stroke due to an LVO who underwent mechanical thrombectomy (MT) and (2) all patients with minor clinical deficits (NIHSS ≤ 4) on admission due to an LVO between January 2013 and December 2016 at the University Medical Center Erlangen. We dichotomized management of patients with minor deficits treated with MT for analysis according to immediate mechanical thrombectomy (IT) and initial medical management with rescue intervention (MM) in case of secondary deterioration. Primary endpoints were secondary deterioration, in-hospital mortality, and functional outcome on day 90 (dichotomized modified Rankin Scale 0–2: favorable, 3–6: poor). Results: Two hundred twenty-three patients (83% with anterior circulation stroke, 13 (6%) with minor deficits) treated with MT and 88 patients with minor deficits due to LVO [13 (15%) treated with MT] were included. Secondary deterioration (n = 19) was independently associated with poor outcome in patients with minor deficits and LVO [odds ratio (OR), 0.060; 95% confidence interval (CI), 0.013–0.280], which in turn was associated with the occlusion site [especially M1 occlusion: 11 (58%) vs. 3 (4%) in patients without secondary deterioration, p < 0.0001]. IT (n = 8) was associated with a lower intrahospital mortality compared to MM (n = 5; 13 vs. 80%; OR, 0.036; 95% CI, 0.002–0.741). Seven of eight patients with IT survived until discharge, with 29% showing a favorable functional outcome on day 90. Conclusions: Secondary deterioration is associated with poor outcome in patients with LVO and minor deficits, which in turn was associated with occlusion site. Future randomized controlled trials should assess whether selected patients, depending on occlusion site and associated characteristics, may benefit from MT.
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Affiliation(s)
- Bastian Volbers
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Rebecca Gröger
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Armin Marsch
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Lang
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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23
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Meng X, Ji J. Infarct volume and outcome of cerebral ischaemia, a systematic review and meta-analysis. Int J Clin Pract 2021; 75:e14773. [PMID: 34478602 DOI: 10.1111/ijcp.14773] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Multiple studies have evaluated the accuracy of infarct volume (IV) as a predictor of outcome in patients with ischaemic stroke; however, no study has systematically reviewed the results of these studies. AIM This systematic review and meta-analysis aim to sum up the results of the studies evaluating IV as the prognostic criteria for patients with cerebral ischaemia. METHODS Human studies that reported the infarction volume and any prognostic outcome in patients with ischaemic stroke were collected from PubMed, Scopus, Embase and Cochrane library databases. Newcastle-Ottawa Quality Assessment Checklist was applied to evaluate the quality of the included articles. 90-day modified Rankin Scale (mRS) score was used as a meta-analysis outcome. The area under the curve, sensitivity and specificity among included studies was evaluated. The heterogeneity of the studies was assessed by Cochran test Egger and Begg test was used for assessing publication bias. RESULTS Among the included studies, nine studies assessed the association between IV and outcome (90-day mRS score). The results of the meta-analysis revealed a significant association between IV with the unfavourable functional outcome (mRS score of 3-6) (OR = 0.80; 95% CI: 0.74-0.86 per 10 mL, P < .001; I2 = 98.1%, P < .001). The infarction volume cut of point between 20 and 50 mL showed the best sensitivity and specificity for the prediction of poor clinical outcomes in patients with ischaemic stroke. CONCLUSION The results of the meta-analysis revealed a significant association between IV and unfavourable functional outcomes in patients with ischaemic stroke.
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Affiliation(s)
- Xianbing Meng
- Department of Neurosurgery, The Second Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Jianwen Ji
- Neurological Center, The Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), Chongqing, China
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24
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He L, Wang J, Wang F, Zhang L, Zhang L, Zhao W, Weng X, Xu F. The length of susceptibility vessel sign predicts early neurological deterioration in minor acute ischemic stroke with large vessel occlusion. BMC Neurol 2021; 21:421. [PMID: 34715818 PMCID: PMC8557057 DOI: 10.1186/s12883-021-02455-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/21/2021] [Indexed: 02/08/2023] Open
Abstract
Background Patients with acute large vessel occlusion (LVO) presenting with minor stroke are at risk of early neurological deterioration (END). The present study aimed to evaluate the frequency and potential predictors of END in patients with medical management and LVO presenting with minor stroke. The relationship between SVS length and END was also investigated. Methods This was a prospective multicenter study. Consecutive patients were collected with anterior circulation. LVO presented with minor stroke [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] within 24 h following onset. END was defined as a deterioration of NIHSS ≥4 within 24 h, without parenchymal hemorrhage. The length of the susceptibility vessel sign (SVS) was measured using the T2* gradient echo imaging. Results A total of 134 consecutive patients with anterior circulation LVO presenting with minor stroke were included. A total of 27 (20.15%) patients experienced END following admission. Patients with END exhibited longer SVS and higher baseline glucose levels compared with subjects lacking END (P < 0.05). ROC curve analysis indicated that the optimal cutoff point SVS length for END was SVS ≥ 9.45 mm. Multivariable analysis indicated that longer SVS [adjusted odds ratio (aOR), 2.03; 95% confidence interval (CI), 1.45–2.84; P < 0.001] and higher baseline glucose (aOR,1.02; 95% CI, 1.01–1.03; P = 0.009) levels were associated with increased risk of END. When SVS ≥ 9.45 mm was used in the multivariate logistic regression, SVS ≥ 9.45 mm (aOR, 5.41; 95%CI, 1.00–29.27; P = 0.001) and higher baseline glucose [aOR1.01; 95%CI, 1.00–1.03; P = 0.021] were associated with increased risk of END. Conclusions END was frequent in the minor stroke patients with large vessel occlusion, whereas longer SVS and higher baseline glucose were associated with increased risk of END. SVS ≥ 9.45 mm was a powerful independent predictor of END.
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Affiliation(s)
- Lanying He
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Jian Wang
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Feng Wang
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Lili Zhang
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Lijuan Zhang
- Department of Neurology, The Second Affiliated Hospital of Chengdu College, Nuclear Industry 416 Hospital, Chengdu, 610021, People's Republic of China
| | - Wang Zhao
- Department of Neurology, Yongchuan Hospital, Chongqing Medical University, Chongqing, 610020, People's Republic of China
| | - Xiechuan Weng
- Beijing Institute of Basic Medical Sciences, Beijing, 100850, China.
| | - Fan Xu
- School of Public Health Chengdu Medical College, Chengdu, 610500, Sichuan, China.
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25
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Romano JG, Gardener H, Smith EE, Campo-Bustillo I, Khan Y, Tai S, Riley N, Sacco RL, Khatri P, Alger HM, Mac Grory B, Gulati D, Sangha NS, Olds KE, Benesch CG, Kelly AG, Brehaut SS, Kansara AC, Schwamm LH. Frequency and Prognostic Significance of Clinical Fluctuations Before Hospital Arrival in Stroke. Stroke 2021; 53:482-487. [PMID: 34645285 DOI: 10.1161/strokeaha.121.034124] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized. METHODS A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines-Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes. RESULTS Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations. CONCLUSIONS Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02072681.
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Affiliation(s)
- Jose G Romano
- University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Hannah Gardener
- University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Iszet Campo-Bustillo
- University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | - Yosef Khan
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Sofie Tai
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Nikesha Riley
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | - Ralph L Sacco
- University of Miami Miller School of Medicine, FL (J.G.R., H.G., I.C.-B., R.L.S.)
| | | | - Heather M Alger
- American Heart Association, Dallas, TX (Y.K., S.T., N.R., H.M.A.)
| | | | - Deepak Gulati
- Ohio State University Wexner Medical Center, Columbus (D.G.)
| | | | | | | | - Adam G Kelly
- University of Rochester Medical Center, NY (C.G.B., A.G.K.)
| | | | - Amit C Kansara
- Providence St. Vincent Medical Center, Portland, OR (A.C.K.)
| | - Lee H Schwamm
- Massachusetts General Hospital/Harvard Medical School, Boston (L.H.S.)
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26
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De Rubeis G, Pampana E, Fabiano S, Bertaccini L, Cotroneo E, Gasperini C. Stroke: Should we treat images or symptoms? A call for trial. Eur J Radiol 2021; 143:109935. [PMID: 34474217 DOI: 10.1016/j.ejrad.2021.109935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Gianluca De Rubeis
- Department of Diagnostic, UOC Neuroradiology Diagnostic and Interventional, San Camillo-Forlanini Hospital, Rome, Italy.
| | - Enrico Pampana
- Department of Diagnostic, UOC Neuroradiology Diagnostic and Interventional, San Camillo-Forlanini Hospital, Rome, Italy
| | - Sebastiano Fabiano
- Department of Diagnostic, UOC Neuroradiology Diagnostic and Interventional, San Camillo-Forlanini Hospital, Rome, Italy
| | - Luca Bertaccini
- Department of Diagnostic, UOC Neuroradiology Diagnostic and Interventional, San Camillo-Forlanini Hospital, Rome, Italy
| | - Enrico Cotroneo
- Department of Diagnostic, UOC Neuroradiology Diagnostic and Interventional, San Camillo-Forlanini Hospital, Rome, Italy
| | - Claudio Gasperini
- Department of Neuroscience, UOC Neurology, S Camillo Forlanini Hospital, Rome Italy
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27
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Seners P, Ben Hassen W, Lapergue B, Arquizan C, Heldner MR, Henon H, Perrin C, Strambo D, Cottier JP, Sablot D, Girard Buttaz I, Tamazyan R, Preterre C, Agius P, Laksiri N, Mechtouff L, Béjot Y, Duong DL, Mounier-Vehier F, Mione G, Rosso C, Lucas L, Papassin J, Aignatoaie A, Triquenot A, Carrera E, Niclot P, Obadia A, Lyoubi A, Garnier P, Crainic N, Wolff V, Tracol C, Philippeau F, Lamy C, Soize S, Baron JC, Turc G. Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone. JAMA Neurol 2021; 78:321-328. [PMID: 33427887 DOI: 10.1001/jamaneurol.2020.4557] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance The best reperfusion strategy in patients with acute minor stroke and large vessel occlusion (LVO) is unknown. Accurately predicting early neurological deterioration of presumed ischemic origin (ENDi) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy. Objective To develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke and LVO. Design, Setting, and Participants This multicentric retrospective cohort included 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score of 5 or less) and LVO (basilar artery, internal carotid artery, first [M1] or second [M2] segment of middle cerebral artery) intended for IVT alone in 45 French stroke centers, ie, including those who eventually received rescue thrombectomy because of ENDi. For external validation, another cohort of 347 patients with similar inclusion criteria was collected from 9 additional centers. Data were collected from January 2018 to September 2019. Main Outcomes and Measures ENDi, defined as 4 or more points' deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause. Results Of the 729 patients in the derivation cohort, 335 (46.0%) were male, and the mean (SD) age was 70 (15) years; of the 347 patients in the validation cohort, 190 (54.8%) were male, and the mean (SD) age was 69 (15) years. In the derivation cohort, the median (interquartile range) NIHSS score was 3 (1-4), and the occlusion site was the internal carotid artery in 97 patients (13.3%), M1 in 207 (28.4%), M2 in 395 (54.2%), and basilar artery in 30 (4.1%). ENDi occurred in 88 patients (12.1%; 95% CI, 9.7-14.4) and was strongly associated with poorer 3-month outcomes, even in patients who underwent rescue thrombectomy. In multivariable analysis, a more proximal occlusion site and a longer thrombus were independently associated with ENDi. A 4-point score derived from these variables-1 point for thrombus length and 3 points for occlusion site-showed good discriminative power for ENDi (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (ENDi rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, ENDi probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively. Conclusions and Relevance The substantial ENDi rates observed in these cohorts highlights the current debate regarding whether to directly transfer patients with IVT-treated minor stroke and LVO for additional thrombectomy. Based on the strong associations observed, an easily applicable score for ENDi risk prediction that may assist decision-making was derived and externally validated.
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Affiliation(s)
- Pierre Seners
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Wagih Ben Hassen
- Radiology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | | | | | - Mirjam R Heldner
- Neurology Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Hilde Henon
- Neurology Department, CHU Lille, Université de Lille, INSERM U1171, Lille, France
| | - Claire Perrin
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Davide Strambo
- Stroke Center, Neurology Service, CHU Vaudois, Lausanne University, Lausanne, Switzerland
| | | | - Denis Sablot
- Neurology Department, Perpignan Hospital, Perpignan, France
| | | | - Ruben Tamazyan
- Neurology Department, Saint Joseph Hospital, Paris, France
| | - Cécile Preterre
- Neurology Department, Nantes University Hospital, Nantes, France
| | - Pierre Agius
- Neurology Department, Nantes University Hospital, Nantes, France.,Neurology Department, St Nazaire Hospital, Saint-Nazaire, France
| | - Nadia Laksiri
- Neurology Department, La Timone University Hospital, Marseille, France
| | - Laura Mechtouff
- Department of Stroke Medicine, Hospices Civils de Lyon, Lyon, France
| | - Yannick Béjot
- Neurology Department, Dijon University Hospital, Dijon, France
| | - Duc-Long Duong
- Neurology Department, Versailles University Hospital, Versailles, France
| | | | - Gioia Mione
- Neurology Department, Nancy University Hospital, Nancy, France
| | - Charlotte Rosso
- Sorbonne Université, Institut du Cerveau et de la Moelle épinière, ICM, INSERM U 1127, CNRS UMR 7225, AP-HP, Urgences Cérébro-Vasculaires, ICM Infrastructure Stroke Network, Hôpital Pitié-Salpêtrière, Paris, France
| | - Ludovic Lucas
- Stroke Unit, Bordeaux University Hospital, Bordeaux, France
| | - Jérémie Papassin
- Stroke Unit, Grenoble University Hospital, Grenoble, France.,Neurology Department, Centre Hospitalier Metropole-Savoie, Chambery, France
| | - Andreea Aignatoaie
- Neurology Department, Centre Hospitalier Régional d'Orléans, Orléans, France
| | | | - Emmanuel Carrera
- Neurology Department, Geneve University Hospital, Geneve, Switzerland
| | | | - Alexandre Obadia
- Neurology Department, Fondation Adolphe de Rothschild, Paris, France
| | - Aïcha Lyoubi
- Neurology Department, Delafontaine Hospital, Saint-Denis, France
| | - Pierre Garnier
- Stroke Unit, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Nicolae Crainic
- Neurology Department, Brest University Hospital, Brest, France
| | - Valérie Wolff
- Neurology Department, Strasbourg University Hospital, Strasbourg, France
| | - Clément Tracol
- Neurology Department, Rennes University Hospital, Rennes, France
| | | | - Chantal Lamy
- Neurology Department, Amiens University Hospital, Amiens, France
| | - Sébastien Soize
- Neuroradiology Department, Reims University Hospital, Reims, France
| | - Jean-Claude Baron
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Guillaume Turc
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
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28
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Sykora M, Krebs S, Simader F, Gattringer T, Greisenegger S, Ferrari J, Bernegger A, Posekany A, Lang W. Intravenous thrombolysis in stroke with admission NIHSS score 0 or 1. Int J Stroke 2021; 17:109-119. [PMID: 33568019 DOI: 10.1177/1747493021991969] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Up to 30% of stroke patients initially presenting with non-disabling or mild deficits may experience poor functional outcome. Despite, intravenous thrombolysis remains controversial in this subgroup of stroke patients due to its uncertain risk benefit ratio. AIM We aimed to analyze the real-world experience with intravenous thrombolysis in stroke patients presenting with very low NIHSS. METHODS Data of stroke patients presenting with mild initial stroke severity (NIHSS 0-5) including vascular risk factors, stroke syndrome and etiology, early neurological deterioration, symptomatic intracerebral haemorrhage (sICH), and functional outcome by modified Rankin Scale were extracted from a large nationwide stroke registry and analysed. Patients were categorized and compared according to admission severity NIHSS 0-1 versus NIHSS 2-5 and intravenous thrombolysis use. RESULTS Seven hundred and three (2%) of 35,113 patients presenting with NIHSS 0-1 and 6316 (13.9%) of 45,521 of patients presenting with NIHSS 2-5 underwent intravenous thrombolysis. In the NIHSS 0-1 group, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 8.84, CI 6.61-11.83), sICH (adjusted OR 9.32, CI 4.53-19.15) and lower rate of excellent outcome (mRS 0-1) at three months (adjusted OR 0.67, CI 0.5-0.9). In stroke patients with NIHSS 2-5, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 1.7, 1.47-1.98), sICH (adjusted OR 5.75, CI 4.45-7.45), and higher rate of excellent outcome (mRS 0-1) at three months (adjusted OR 1.21, CI 1.08-1.34). CONCLUSIONS Among patients with NIHSS 0-1, intravenous thrombolysis did not increase the likelihood of excellent outcome. Moreover, potential signals of harm were observed. Further research seems to be warranted.
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Affiliation(s)
- Marek Sykora
- Medical Faculty, Sigmund Freud University Vienna, Austria.,Department of Neurology, St John's Hospital, Vienna, Austria
| | - Stefan Krebs
- Department of Neurology, St John's Hospital, Vienna, Austria
| | | | | | | | - Julia Ferrari
- Department of Neurology, St John's Hospital, Vienna, Austria
| | | | - Alexandra Posekany
- Research Unit of Computational Statistics, University of Technology, Vienna
| | - Wilfried Lang
- Medical Faculty, Sigmund Freud University Vienna, Austria.,Department of Neurology, St John's Hospital, Vienna, Austria
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29
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Gwak DS, Kwon JA, Shim DH, Kim YW, Hwang YH. Perfusion and Diffusion Variables Predict Early Neurological Deterioration in Minor Stroke and Large Vessel Occlusion. J Stroke 2021; 23:61-68. [PMID: 33600703 PMCID: PMC7900396 DOI: 10.5853/jos.2020.01466] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/01/2020] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose Patients with acute large vessel occlusion (LVO) presenting with mild stroke symptoms are at risk of early neurological deterioration (END). This study aimed to identify the optimal imaging variables for predicting END in this population.
Methods We retrospectively analyzed 94 patients from the prospectively maintained institutional stroke registry admitted between January 2011 and May 2019, presenting within 24 hours after onset, with a baseline National Institutes of Health Stroke Scale score ≤5 and anterior circulation LVO. Patients who underwent endovascular therapy before END were excluded. Volumes of Tmax delay (at >2, >4, >6, >8, and >10 seconds), mismatch (Tmax >4 seconds – diffusion-weighted imaging [DWI] and Tmax >6 seconds – DWI), and mild hypoperfusion lesions (Tmax 2–6 and 4–6 seconds) were measured. The association of each variable with END was examined using receiver operating characteristic curves. The variables with best predictive performance were dichotomized at the cutoff point maximizing Youden’s index and subsequently analyzed using multivariable logistic regression.
Results END occurred in 39.4% of the participants. The optimal variables were identified as Tmax >6 seconds, Tmax >6 seconds – DWI, and Tmax 4–6 seconds with cut-off points of 53.73, 32.77, and 55.20 mL, respectively. These variables were independently associated with END (adjusted odds ratio [aOR], 12.78 [95% confidence interval (CI), 3.36 to 48.65]; aOR, 5.73 [95% CI, 2.04 to 16.08]; and aOR, 9.13 [95% CI, 2.76 to 30.17], respectively).
Conclusions Tmax >6 seconds, Tmax >6 seconds – DWI, and Tmax 4–6 seconds could identify patients at high risk of END following minor stroke due to LVO.
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Affiliation(s)
- Dong-Seok Gwak
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea
| | - Jung-A Kwon
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea
| | - Dong-Hyun Shim
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea
| | - Yong-Won Kim
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
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30
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Nguyen TH, Pham BN, Phan HT, Nguyen TQ, Phan BV. Perfusion-Based Decision-Making for Mechanical Thrombectomy in a Transient Ischemic Attack Patient with Middle Cerebral Artery Occlusion. Case Rep Neurol 2021; 12:41-48. [PMID: 33505271 DOI: 10.1159/000507753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 04/03/2020] [Indexed: 11/19/2022] Open
Abstract
A significant proportion of patients with large-vessel occlusion (LVO) initially present to the hospital with transient ischemic attack (TIA) and mild clinical manifestations such as low National Institutes of Health Stroke Scale (NIHSS) scores (≤5). However, due to the natural course of the disease, the individuals may subsequently develop worsening symptoms. To date, there is lack of evidence-based guidelines on mechanical thrombectomy (MT) among those patients. Therefore, the predicting factors associated with better or worse outcomes for acute stroke patients receiving MT compared to those not receiving the treatment are unknown. We describe a TIA case with LVO who was treated with MT; we used perfusion imaging as a decision aid. A 55-year-old male patient with a past medical history of TIA, hypertension, and hyperlipidemia was admitted to our hospital for evaluation of transient mild right hemiparesis and dysarthria lasting for 5 min 3 h before admission. He reported that he had experienced the same condition 1 day before. On admission, neurological examination showed normal function with an NIHSS score of 0. Computed tomography angiography revealed left proximal M1 occlusion. In addition, perfusion magnetic resonance imaging maps calculated by the RAPID software showed acute small lesions on the left hemisphere with core volume (0 mL) and a large ischemic penumbra (70 mL). Immediate endovascular thrombectomy was performed 5 h following symptom onset with complete recanalization and clinical recovery. The case suggests that MT in LVO patients with low NIHSS scores, even a score of 0, on presentation is potentially a safe and effective treatment. The use of perfusion imaging in the acute phase of stroke should be encouraged for the decision-making process.
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Affiliation(s)
- Thang Huy Nguyen
- Cerebrovascular Disease Department, 115 People's Hospital, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Binh Nguyen Pham
- Cerebrovascular Disease Department, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Hoang Thi Phan
- Cerebrovascular Disease Department, 115 People's Hospital, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Trung Quoc Nguyen
- Cerebrovascular Disease Department, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Bau Van Phan
- Cerebrovascular Disease Department, 115 People's Hospital, Ho Chi Minh City, Vietnam
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31
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Goyal M, Ospel JM. Adapting pre-hospital stroke triage systems to expanding thrombectomy indications. Neuroradiology 2021; 63:161-166. [PMID: 33439296 DOI: 10.1007/s00234-021-02638-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada. .,Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.
| | - Johanna M Ospel
- , Calgary, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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32
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Ostrý S, Nevšímal M, Nevšímalová M, Reiser M, Fiedler J. Median somatosensory evoked potential as a predictor of clinical outcome after urgent surgical extracranial internal carotid artery recanalization. Clin Neurophysiol 2020; 132:372-381. [PMID: 33450560 DOI: 10.1016/j.clinph.2020.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/04/2020] [Accepted: 11/27/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Changes in the N20/P25 amplitude of somatosensory evoked potentials (SEP) of the median nerve have been found to correlate with those in cortical regional cerebral blood flow (rCBF). Our study presents the use of median nerve SEP amplitude in predicting the clinical outcome of urgent surgical internal carotid artery (ICA) recanalization. METHODS A total of 27 patients suffering an acute ischemic stroke (AIS) with extracranial ICA occlusion within 24 h were prospectively recruited. The primary preoperative endpoints included the SEP amplitude absolute value (SEP-amp) and the SEP amplitude side-to-side ratio (SEP-ratio). Clinical outcome at 3 months postoperatively was assessed using the modified Rankin scale (mRS-3M). RESULTS The positive predictive values (PPVs) for SEP-amp and SEP-ratio were 95.5% and 100%, respectively, with the negative predictive values (NPVs) being 60.0% and 100%, respectively. The SEP-ratio correlated fully with mRS-3M. CONCLUSION The median SEP side-to-side N20/P25 amplitude ratio seems to be a very strong positive and negative predictor of the clinical outcome of urgent recanalization of an extracranial ICA occlusion. SIGNIFICANCE The results suggest that cortical evoked activity may help in selection patient for surgical recanalization and predict clinical recovery after an acute ischemic stroke.
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Affiliation(s)
- Svatopluk Ostrý
- Department of Neurology, České Budějovice Hospital, České Budějovice, Czech Republic; Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital, Prague, Czech Republic.
| | - Milan Nevšímal
- Department of Neurosurgery, České Budějovice Hospital, České Budějovice, Czech Republic.
| | - Miroslava Nevšímalová
- Department of Neurology, České Budějovice Hospital, České Budějovice, Czech Republic.
| | - Martin Reiser
- Department of Neurology, České Budějovice Hospital, České Budějovice, Czech Republic.
| | - Jiří Fiedler
- Department of Neurosurgery, České Budějovice Hospital, České Budějovice, Czech Republic; Department of Neurosurgery, Faculty of Medicine in Plzeň, Charles University in Prague, Czech Republic.
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33
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McCarthy DJ, Tonetti DA, Stone J, Starke RM, Narayanan S, Lang MJ, Jadhav AP, Gross BA. More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores. J Neurointerv Surg 2020; 13:146-151. [PMID: 33028674 DOI: 10.1136/neurintsurg-2020-016583] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.
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Affiliation(s)
- David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Stone
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Department of Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Sandra Narayanan
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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34
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Volny O, Zerna C, Tomek A, Bar M, Rocek M, Padr R, Cihlar F, Nevsimalova M, Jurak L, Havlicek R, Kovar M, Sevcik P, Rohan V, Fiksa J, Cernik D, Jura R, Vaclavik D, Cimflova P, Puig J, Dowlatshahi D, Khaw AV, Fainardi E, Najm M, Demchuk AM, Menon BK, Mikulik R, Hill MD. Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke. Neurology 2020; 95:e3364-e3372. [PMID: 32989100 DOI: 10.1212/wnl.0000000000010955] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/12/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To undertake an effectiveness and safety analysis of EVT in patients with LVO and NIH Stroke Scale (NIHSS) score ≤6 using datasets of multicenter and multinational nature. METHODS We pooled patients with anterior circulation occlusion from 3 prospective international cohorts. Patients were eligible if presentation occurred within 12 hours from last known well and baseline NIHSS ≤6. Primary outcome was modified Rankin Scale (mRS) score 0-1 at 90 days. Secondary outcomes included neurologic deterioration at 24 hours (change in NIHSS of ≥2 points), mRS 0-2 at 90 days, and 90-day all-cause mortality. We used propensity score matching to adjust for nonrandomized treatment allocation. RESULTS Among 236 patients who fit inclusion criteria, 139 received EVT and 97 received medical management. Compared to medical management, the EVT group was younger (65 vs 72 years; p < 0.001), had more proximal occlusions (p < 0.001), and less frequently received concurrent IV thrombolysis (57.7% vs 71.2%; p = 0.04). After propensity score matching, clinical outcomes between the 2 groups were not significantly different. EVT patients had an 8.6% (95% confidence interval [CI] -8.8% to 26.1%) higher rate of excellent 90-day outcome, despite a 22.3% (95% CI, 3.0%-41.6%) higher risk of neurologic deterioration at 24 hours. CONCLUSIONS EVT for LVO in patients with low NIHSS score was associated with increased risk of neurologic deterioration at 24 hours. However, both EVT and medical management resulted in similar proportions of excellent clinical outcomes at 90 days. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with acute anterior circulation ischemic strokes and LVO with NIHSS < 6, EVT and medical management result in similar outcomes at 90 days.
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Affiliation(s)
- Ondrej Volny
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Charlotte Zerna
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy.
| | - Ales Tomek
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Michal Bar
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Miloslav Rocek
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Radek Padr
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Filip Cihlar
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Miroslava Nevsimalova
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Lubomir Jurak
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Roman Havlicek
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Martin Kovar
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Petr Sevcik
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Vladimir Rohan
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Jan Fiksa
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - David Cernik
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Rene Jura
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Daniel Vaclavik
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Petra Cimflova
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Josep Puig
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Dar Dowlatshahi
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Alexander V Khaw
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Enrico Fainardi
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Mohamed Najm
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Andrew M Demchuk
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Bijoy K Menon
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Robert Mikulik
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
| | - Michael D Hill
- From the Department of Clinical Neurosciences, Calgary Stroke Program (O.V., C.Z., M.N., A.M.D., B.K.M., M.D.H.), and Department of Community Health Sciences (C.Z., B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, Canada; International Clinical Research Centre, Stroke Research Program & Department of Neurology (O.V., P.C., R.M.), and Department of Medical Imaging (P.C.), St. Anne's University Hospital; Faculty of Medicine (O.V., P.C., R.M.), Masaryk University, Brno; Department of Neurology (O.V.), Faculty Hospital Ostrava; 2nd Medical Faculty (A.T.) and First Faculty of Medicine and General University Hospital (J.F.), Department of Neurology, Charles University, Prague; Department of Neurology, Faculty of Medicine (M.B.), University Hospital Ostrava, University Ostrava; Department of Radiology, 2nd Faculty of Medicine (M.R., R.P.), Charles University in Prague and Motol University Hospital; Department of Radiology (F.C.) and Department of Neurology-Comprehensive Stroke Center (D.C.), Masaryk Hospital, Usti nad Labem; Department of Neurology (M.N.), Hospital Ceske Budejovice; Neurocenter (L.J.), Regional Hospital Liberec; Department of Neurology (R.H.), Military University Hospital, Prague; Department of Neurology (M.K.), Na Homolce Hospital, Prague; Department of Neurology, Faculty of Medicine in Pilsen (P.S., V.R.), Charles University in Prague, Pilsen; Department of Neurology (R.J.), University Hospital Brno and Faculty of Medicine Masaryk University; Department of Neurology (D.V.), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR) (J.P.), Parc Sanitari Pere Virgili, Barcelona; Girona Biomedical Research Institute (IDIBGI)-Medical Imaging (J.P.), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Department of Clinical Neurosciences (D.P.), University of Western Ontario; Lawson Health Research Institute and Robarts Research Institute (A.V.K.), London, Canada; and Department of Experimental and Clinical Biomedical Sciences "Mario Serio" (E.F.), University of Florence, Italy
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Zhao Y, Song Y, Guo Y, Li Y, Zhang Y, Ma P, Li G, Li F. Endovascular Thrombectomy VS. Medical Treatment for Mild Stroke Patients: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2020; 29:105258. [PMID: 32992178 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/15/2020] [Accepted: 08/16/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE At present, endovascular thrombectomy (EVT) has been gradually became a standard therapy for stroke patients caused by emergent large-vessel occlusion (ELVO). However, the question about whether EVT is superior to medical treatment for mild stroke patients presenting with a low baseline National Institutes of Health Stroke Scale (NIHSS) score remains unclear. The aim of this systematic review and meta-analysis was to compare the safety and efficacy of EVT with medical treatment in mild stroke patients. MATERIAL AND METHODS A systematic review and meta-analysis was conducted through searching the PubMed, Embase and Cochrane Library databases. All statistical analyses were performed by using Review Manager 5.3 software. Primary outcomes of this meta-analysis were as follows: favorable functional outcome at 90 days (defined as a modified Rankin scale (mRS) score of 0-2); excellent functional outcome at 90 days (defined as a mRS score of 0-1); symptomatic intracerebral hemorrhage (sICH); mortality at 90 days. RESULTS A total of 13 eligible studies with 2135 patients were included in this meta-analysis. The pooled results indicated that mild stroke patients underwent EVT had higher risk of sICH than those receiving medical treatment alone (OR = 3.21; 95% CI, 1.98-5.22; P < 0.001). In addition, no significant difference was found between the two groups in mortality at 90 days (OR = 1.80; 95% CI, 0.88-3.65; P=0.11). Meanwhile, no significant difference was found between the two groups in patients achieving favorable functional outcome at 90 days and excellent functional outcome at 90 days (OR = 1.10; 95% CI, 0.74-1.64; P = 0.65) (OR = 1.03; 95% CI, 0.79-1.35; P = 0.80). CONCLUSIONS Our pooled results showed similar clinical outcomes at 90 days of EVT and medical treatment in mild stroke patients with ELVO, although patients underwent EVT had higher rates of sICH. However, due to several limitations of this meta-analysis, randomized controlled trials are needed to further evaluate the potential efficacy of EVT in mild stroke patients.
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Affiliation(s)
- Yongli Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China
| | - Ying Song
- Department of Pathology, Xinxiang Medical University, Xinxiang, Henan 453000, China
| | - Yingchang Guo
- Department of Interventional Radiology, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China
| | - Yanru Li
- Department of Neurosurgery Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Yi Zhang
- Department of Neurology, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China
| | - Pengju Ma
- Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China
| | - Guangpeng Li
- Department of Emergency, The First Affiliated Hospital, Xinxiang Medical University, Weihui 453100, Henan, China
| | - Fenbao Li
- Department of Interventional Radiology, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China.
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Saleem Y, Nogueira RG, Rodrigues GM, Kim S, Sharashidze V, Frankel M, Al-Bayati A, Bianchi N, Haussen DC. Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically. Stroke 2020; 51:1428-1434. [DOI: 10.1161/strokeaha.119.027011] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
It is unclear which factors predict acute neurological deterioration in patients with large vessel occlusion and mild symptoms. We aim to evaluate the frequency, timing, and potential predictors of acute neurological deterioration ≥4 National Institutes of Health Stroke Scale (NIHSS) points in medically managed patients with large vessel occlusion and mild presentation.
Methods—
Single-center retrospective study of patients with consecutive minor stroke (defined as NIHSS score of ≤5 on presentation) and large vessel occlusion from January 2014 to December 2017. Primary outcome was acute neurological deterioration ≥4 NIHSS points during the hospitalization. Secondary outcomes included ΔNIHSS (defined as discharge minus admission NIHSS score).
Results—
Among 1133 patients with acute minor strokes, 122 (10.6%) had visible occlusions on computed tomography angiography/magnetic resonance angiography. Twenty-four (19.7%) patients had ≥4 points deterioration on NIHSS at a median of 3.6 (1–16) hours from arrival. No clinical or radiological predictors of acute neurological deterioration ≥4 NIHSS points were observed on multivariable analysis. Rescue endovascular thrombectomy was performed more often in the ones with acute neurological deterioration ≥4 NIHSS points compared with patients with no deterioration (54% versus 0%;
P
<0.001). Acute neurological deterioration ≥4 NIHSS points was associated with ΔNIHSS ≥4 points (33% versus 4.9%;
P
<0.01) and a trend toward lower independence rates at discharge (50% versus 70%;
P
=0.06) compared with the group with no deterioration. In patients with any degree of neurological worsening, patients who underwent rescue thrombectomy were more likely to be independent at discharge (73% versus 38%;
P
=0.02) and to have a favorable ΔNIHSS (−2 [−3 to 0] versus 0 [−1 to 6];
P
=0.05) compared with the ones not offered rescue thrombectomy.
Conclusions—
Acute neurological deterioration ≥4 NIHSS points was observed in a fifth of patients with large vessel occlusion and mild symptoms, occurred very early in the hospital course, impacted functional outcomes, and could not be predicted by any of the studied clinical and radiological variables. Rescue thrombectomy was associated with improved clinical outcomes at discharge in patients with neurological deterioration.
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Affiliation(s)
- Yasir Saleem
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Raul G. Nogueira
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Gabriel M. Rodrigues
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Song Kim
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Vera Sharashidze
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Michael Frankel
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Alhamza Al-Bayati
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Nicolas Bianchi
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Diogo C. Haussen
- From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA
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Akhtar N, Kamran S, Elkhider H, Al-Makki S, Mhjob N, ElShiekh L, AlHussain H, Ali M, Khodair R, Wadiwala F, Salam A, Deleu D, Francis R, Shuaib A. Progression of stroke deficits in patients presenting with mild symptoms: The underlying etiology determines outcome. PLoS One 2020; 15:e0231448. [PMID: 32330144 PMCID: PMC7182193 DOI: 10.1371/journal.pone.0231448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/24/2020] [Indexed: 12/02/2022] Open
Abstract
Background and purpose Patients with acute stroke and mild or rapidly improving symptoms frequently show progression. The role of reperfusion treatment in such patients is not clear. We hypothesized that progression was most likely in patients with cortical localization and such patients may benefit from thrombolysis. Material and methods We interrogated Hamad Stroke Database to evaluate 90-days outcome in patients with acute ischemic stroke admitted within 4 hours and a NIHSS score of ≤6. Evaluation was based on localization (lacunar or cortical), multi-model imaging abnormalities and whether they received rt-PA. The 90-day mRS was used to determine outcome. Results During study period 6381 patients were admitted with acute stroke. Mild stroke within 4 hours was diagnosed in 506 [no thrombolysis: 381(lacunar: 213; cortical: 168), thrombolysis: 125 (lacunar: 45; cortical: 80)]. The rt-PA treated patients had significantly higher NIHSS (2.94±3.9 versus 1.28±2.46, p<0.0001), increased rates of complications (16.0% versus 3.9%, p<0.0001) and longer hospital stay (6.05±8.1 versus 3.78±3.6 days; p<0.001). In patients with cortical stroke, intracranial arterial occlusions (11.6% vs 3.9%, p<0.0001) and CTP mismatch (22.2% vs 4.4%, p<0.0001) were more frequent in rt-PA treated patients. Discharge mRS (33.6% versus 13.9%, p<0.001) and 90-days mRS (23.2% versus 11.8%, p = 0.002) was significantly worse in patients with cortical stroke (rt-PA-treated and untreated patients). Conclusions The outcome in patients with mild stroke depends on lesion location (lacunar versus cortical) and severity of symptoms. Patients who receive rt-PA have significantly larger deficits, increased imaging abnormalities and higher rates of hospital complication, explaining the poor outcome in such subjects.
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Affiliation(s)
- Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Hisham Elkhider
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Soha Al-Makki
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Noha Mhjob
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Lubna ElShiekh
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Hassan AlHussain
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Musab Ali
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Rola Khodair
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Faisal Wadiwala
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Salam
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Reny Francis
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, Stroke Program, University of Alberta, Edmonton, Canada
- * E-mail: ,
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Min SH, Kim JT, Kang KW, Choi MJ, Yoon H, Shinohara Y, Lev MH, Saver JL, Cho KH. Acute insular infarction: Early outcomes of minor stroke with proximal artery occlusion. PLoS One 2020; 15:e0229836. [PMID: 32160209 PMCID: PMC7065779 DOI: 10.1371/journal.pone.0229836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/14/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE We hypothesized that admission insular infarcts could be associated with early neurological deterioration (END) in acute minor stroke with large vessel occlusion. METHODS Using acute and follow-up diffusion-weighted imaging (DWI), we assessed insular involvement including the percent insular ribbon infarction (PIRI) scores and follow-up lesion patterns in acute minor stroke (NIHSS ≤5) with MCA/ICA occlusion. Follow-up lesion patterns were classified as swelling, new lesions, or infarct growth. END was defined as any increase in the NIHSS score. RESULTS Among 166 patients (age: 66±12 y, 60.8% male), 82 (49.4%) had insular lesions on baseline DWI, and 64 (38.6%) had PIRI scores ≥2. On follow-up DWI, infarct growths, new lesions, and swelling were observed in 34.9%, 69.9%, and 29.5% of patients. Infarct growths were significantly more frequent in patients with insular infarcts (43.9%), especially those with a PIRI score of 2 (54.8%), than in patients without insular infarcts (p = 0.02). While END was not significantly different in patients with and without insular lesions, insular lesions were independently associated with infarct growths (OR 2.18, 95% CI 1.12-4.26, p = 0.02) and END due to infarct growth (OR 2.54, 95% CI 1.12-5.76, p = 0.03), particularly in those with PIRI scores ≥2. CONCLUSION In acute minor stroke with MCA/ICA occlusion, insular lesions on admission DWI, especially in patients with PIRI scores ≥2, were more likely to exhibit infarct growth and END due to infarct growth. This finding may help identify patients with higher risks of clinical worsening following acute minor stroke with large vessel occlusion.
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Affiliation(s)
- Seung-Hyun Min
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
- * E-mail:
| | - Kyung-Wook Kang
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
| | - Min-Ji Choi
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
| | - Hana Yoon
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
| | - Yuki Shinohara
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Michael H. Lev
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
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Heldner MR, Chaloulos-Iakovidis P, Panos L, Volbers B, Kaesmacher J, Dobrocky T, Mordasini P, El-Koussy M, Gralla J, Arnold M, Fischer U, Mattle HP, Jung S. Outcome of patients with large vessel occlusion in the anterior circulation and low NIHSS score. J Neurol 2020; 267:1651-1662. [PMID: 32062782 DOI: 10.1007/s00415-020-09744-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Optimal management of patients with large vessel occlusion (LVO) and low NIHSS score is unknown, which was the aim to investigate in this study. METHODS This is a retrospective analysis of a prospective single tertiary care centre 14-year cohort of patients with LVO in the anterior circulation and NIHSS score ≤ 5 on admission. Outcome was analysed according to primary intended therapy. RESULTS Among 185 patients (median age 67.4 years), 52.4% received primary conservative therapy (including 26.8% secondary reperfusion in case of secondary neurological deterioration), 12.4% IV thrombolysis (IVT) only and 35.1% primary endovascular therapy (EVT). 95 (51.4%) patients experienced neurological deterioration until 3 months. Primary-IVT-only and primary-EVT compared to conservative-therapy patients had better 3 months' outcome (54.5% vs. 30.8%: adjustedOR 6.02; adjustedp = 0.004 for mRS 0-1 and 54.7% vs. 30.8%: adjustedOR 5.09; adjustedp = 0.002, respectively). Also mRS shift analysis favored primary-IVT-only and primary-EVT patients (adjustedOR 6.25; adjustedp = 0.001 and adjustedOR 3.14; adjustedp = 0.003). Outcome in primary-IVT-only vs. primary-EVT patients did not differ significantly. Patients who received secondary EVT because of neurological deterioration after primary-conservative-therapy had worse 3 months' outcome than primary-EVT patients (20.8% vs. 30.8%: adjustedOR 0.24; adjustedp = 0.047 for mRS 0-1 and adjustedOR 0.31; adjustedp = 0.019 in mRS shift analysis). Survival and symptomatic intracranial haemorrhage did not differ amongst groups. CONCLUSIONS Our data indicate that primary IVT and/or EVT may be better than primary conservative therapy in patients with LVO in the anterior circulation and low NIHSS score. Furthermore, primary EVT was better than secondary EVT in case of neurological deterioration. There is an unmet need for RCTs to find the optimal therapy for this patient group.
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Affiliation(s)
- Mirjam R Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland.
| | | | - Leonidas Panos
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Bastian Volbers
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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Endovascular treatment decision-making in acute ischemic stroke patients with large vessel occlusion and low National Institutes of Health Stroke Scale: insights from UNMASK EVT, an international multidisciplinary survey. Neuroradiology 2020; 62:715-721. [DOI: 10.1007/s00234-020-02371-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
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Lee BY, Oh JS, Yoon SM. Long-term Prognosis of Patients Who Contraindicated for Intravenous Thrombolysis in Acute Ischemic Stroke. J Cerebrovasc Endovasc Neurosurg 2019; 21:77-85. [PMID: 31886143 PMCID: PMC6911775 DOI: 10.7461/jcen.2019.21.2.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 12/03/2022] Open
Abstract
Background As intravenous thrombolysis (IVT) has very restricted inclusion criteria, eligible patients of IVT constitute a very small proportion and studies about their mortality are rare. The long-term mortality in a patients with contraindication of ineligible patients of IVT still under the debate. So, we investigated the proportion of patients with contraindication of IVT and the short and long-term mortality of them in AIS on emergency department comparing with the long-term effect of IVT in patients with moderate-to-severe stroke. Methods Using acute stroke assessment indication registry & Health Insurance Review and Assessment Service database, a total of 5,407 patients with NIHSS≥5 were selected from a total of 169 acute stroke care hospital nationwide during October-December 2011 and March-June 2013. We divided AIS patients into two groups: 1) IVT group who received IVT within 4.5 hours, and 2) non-IVT group who did not receive the IVT because of contraindications. And we divided the subgroups according to the reason of contraindication of IVT. The 5-year survival rate of each group was assessed using Kaplan-Meyer survival analysis. Results Of the 5,407 patients, a total of 1,027 (19%) patients who received IVT using r-tPA within 4.5 h after onset. Compared with the IVT group, hazard ratios of non-IVT group were 1.33 at 3 months, 1.53 at 1 year and 1.47 at 5 years (p<.001). A total of 4,380 patients did not receive IVT because of the following contraindications to IVT. 1) Time restriction: 3,378 (77.1 %) patients were admitted after 4.5 h following stroke onset, and 144 (3.3%) patients failed to determine the stroke onset time. 2) Mild symptoms:137 (3.1%) patients had rapid improvement or mild stroke on emergency room, 3) Bleeding diathesis or non-adjustable hypertension: 53 (1.2%) patients showed a bleeding tendency or severe hypertension. Compared with the IVT group, the subgroups of non-IVT group showed consistently high mortality during short and long term follow up. Mild symptom and bleeding diathesis or non-adjustable hypertension subgroup in the non-IVT group consistently showed the higher mortality than time restriction subgroup during the short and long-term follow-up (log-rank p<.001). Patients who had rapid improvement or mild stroke on emergency department had the higher mortality than time restriction group in short and long term follow up. Conclusion The AIS patients with rapid improvement or mild stroke on emergency room had higher mortality than ineligible patients of IVT due to time restriction during the short and long-term follow-up. A further management and special support on emergency department is needed for these patients with initially mild stroke and rapid improvement in AIS to reduce the poor outcome.
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Affiliation(s)
- Bo-Yeon Lee
- Department of Public Health, Graduate school of Korea University, Seoul, South Korea
| | - Jae-Sang Oh
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Cheonnan Hospital, South Korea
| | - Seok-Mann Yoon
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Cheonnan Hospital, South Korea
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Manno C, Disanto G, Bianco G, Nannoni S, Heldner MR, Jung S, Arnold M, Kaesmacher J, Müller M, Thilemann S, Gensicke H, Carrera E, Fischer U, Kahles T, Luft A, Nedeltchev K, Staedler C, Cianfoni A, Kägi G, Bonati LH, Michel P, Cereda CW. Outcome of endovascular therapy in stroke with large vessel occlusion and mild symptoms. Neurology 2019; 93:e1618-e1626. [PMID: 31591276 DOI: 10.1212/wnl.0000000000008362] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/21/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare outcomes after endovascular therapy (EVT) and IV thrombolysis (IVT) in patients with stroke with emergent large vessel occlusion (LVO) and mild neurologic deficits. METHODS This was a retrospective analysis of patients from the Swiss Stroke Registry with admission NIH Stroke Scale score ≤5 and LVO treated by EVT (± IVT) vs IVT alone. The primary endpoint was favorable functional outcome (modified Rankin Scale [mRS] score 0-1) at 3 months. Secondary outcomes were independence (mRS score 0-2), mRS score (ordinal shift analysis), and survival with high disability (mRS score 4-5). Safety endpoints were mortality and symptomatic hemorrhage. RESULTS Of 11,356 patients, 312 met the criteria and propensity score method matched 108 in each group. A comparably large proportion of patients with EVT and IVT had favorable outcome (63% vs 65.7% respectively; odds ratio 0.94, 95% confidence interval 0.51-1.72; p = 0.840). Patients with EVT showed a nonsignificant trend toward higher mRS score at 3 months (p = 0.717), while the proportion of surviving patients with high disability was comparably very low in both groups (p = 0.419). Mortality was slightly higher among those with EVT (9.3% vs 2.8%; p = 0.06), and symptomatic intracranial hemorrhage was a rare event in both groups (2.8% vs 0%; p = 0.997). CONCLUSIONS In acute ischemic stroke, EVT and IVT appear similarly effective in achieving favorable outcome at 3 months for patients with LVO and mild neurologic symptoms. EVT might be marginally inferior to IVT regarding outcome across all levels of disability and mortality. Further studies are required to determine whether certain subgroups of patients with LVO and mild symptoms benefit from EVT. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that patients with LVO and mild symptoms receiving either EVT or IVT had similar favorable functional outcomes at 3 months.
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Affiliation(s)
- Concetta Manno
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Giulio Disanto
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Giovanni Bianco
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Stefania Nannoni
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Mirjam R. Heldner
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Simon Jung
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Marcel Arnold
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Johannes Kaesmacher
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Mandy Müller
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Sebastian Thilemann
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Henrik Gensicke
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Emmanuel Carrera
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Urs Fischer
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Timo Kahles
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Andreas Luft
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Krassen Nedeltchev
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Claudio Staedler
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Alessandro Cianfoni
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Georg Kägi
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Leo H Bonati
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Patrik Michel
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Carlo W Cereda
- From the Stroke Center (C.M., G.D., G.B., C.S., A.C., C.W.C.), Neurocenter of Southern Switzerland, Lugano; Stroke Center and Neurology Service (S.N., P.M., C.W.C.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois); Department of Neurology (M.H., S.J., M.A., U.F.) and Institute of Diagnostic and Interventional Neuroradiology (A.C., J.K.), Institute of Diagnostic, Interventional and Pediatric Radiology, and Department of Neurology, University Hospital Bern and University of Bern, Inselspital; Department of Neurology and Stroke Center (M.M., S.T., H.G., L.H.B.), University Hospital of Basel; Stroke Center (E.C.), Service de Neurologie, HUG, Geneva; Department of Neurology (T.K., K.N.), Cantonal Hospital Aarau; Stroke Center (A.L.), Department of Neurology, University Hospital of Zürich; and Stroke Center (G.K.), Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland.
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Gong P, Xie Y, Jiang T, Liu Y, Wang M, Sun H, Zhang S, Zhang Y, Zhang X, Zhou J. Neutrophil-lymphocyte ratio predicts post-thrombolysis early neurological deterioration in acute ischemic stroke patients. Brain Behav 2019; 9:e01426. [PMID: 31566920 PMCID: PMC6790313 DOI: 10.1002/brb3.1426] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/01/2019] [Accepted: 09/08/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis (IVT) has become the standard treatment for acute ischemic stroke within 4.5 hr after symptoms onset. However, a fraction of patients would develop early neurological deterioration (END) after IVT. The aim of our study was to explore the utility of neutrophil-lymphocyte ratio (NLR) in predicting END. METHODS From October 2016 to March 2018, 342 consecutive patients with thrombolytic therapy were prospectively enrolled in this study. Blood cell counts were sampled in stroke emergency room before IVT. END was defined as a National Institutes of Health Stroke Scale score increase of ≥4 points within 24 hr after IVT. Multiple regression analysis was used to investigate the potential risk factors of END. We also performed receiver operating characteristic curve analysis and nomogram analysis to assess the overall discriminative ability of the NLR in predicting END. RESULTS Of the 342 patients, 86 (25.1%) participants were identified with END. Univariate logistic regression analysis demonstrated that patients with NLR in the third tertile, compared with the first tertile, were more likely to have END (odds ratio, 9.783; 95% confidence interval [CI], 4.847-19.764; p = .001). The association remained significant even after controlled for potential confounders. Also, a cutoff value of 4.43 for NLR was detected in predicting post-thrombolysis END with a sensitivity of 70.9% and a specificity of 79.3% (area under curve, 0.779; 95% CI, 0.731-0.822). Furthermore, our established nomogram indicated that higher NLR was an indicator of post-thrombolysis END (c-index was 0.789, p < .001). CONCLUSIONS This study showed that elevated level of NLR may predict post-thrombolysis END in ischemic stroke patients.
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Affiliation(s)
- Pengyu Gong
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yi Xie
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Teng Jiang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yukai Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Meng Wang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huanhuan Sun
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shuting Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yingdong Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaohao Zhang
- Department of Neurology, Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Haeberlin MI, Held U, Baumgartner RW, Georgiadis D, Valko PO. Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms. Int J Stroke 2019; 15:429-437. [PMID: 31514684 DOI: 10.1177/1747493019874719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Optimal treatment strategy in patients with mild ischemic stroke remains uncertain. While functional dependency or death has been reported in up to one-third of non-thrombolyzed mild ischemic stroke patients, intravenous thrombolysis is currently not recommended in this patient group. Emerging evidence suggests two risk factors-rapid early improvement and large vessel occlusion-as main associates of unfavorable outcome in mild ischemic stroke patients not undergoing intravenous thrombolysis. AIMS To analyze natural course as well as safety and three-month outcome of intravenous thrombolysis in mild ischemic stroke without rapid early improvement or large vessel occlusion. METHODS Mild ischemic stroke was defined by a National Institute of Health Stroke Scale score ≤6. We used the modified Rankin Scale (mRS) to compare three-month functional outcome in 370 consecutive mild ischemic stroke patients without early rapid improvement and without large vessel occlusion, who either underwent intravenous thrombolysis (n = 108) or received best medical treatment (n = 262). RESULTS Favorable outcome (mRS ≤ 1) was common in both groups (intravenous thrombolysis: 91%; no intravenous thrombolysis: 90%). Although intravenous thrombolysis use was independently associated with a higher risk of asymptomatic hemorrhagic transformation (OR = 4.62, p = 0.002), intravenous thrombolysis appeared as an independent predictor of mRS = 0 at three months (OR = 3.33, p < 0.0001). CONCLUSIONS Mild ischemic stroke patients without rapidly improving symptoms and without large vessel occlusion have a high chance of favorable three-month outcome, irrespective of treatment type. Patients receiving intravenous thrombolysis, however, more often achieved complete remission of symptoms, which particularly in mild ischemic stroke may constitute a meaningful endpoint.
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Affiliation(s)
- Marcellina Isabelle Haeberlin
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Horten Center for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Ralf W Baumgartner
- NeuroCenter, Swiss Neuro Institute, Clinic Hirslanden, Zurich, Switzerland
| | - Dimitrios Georgiadis
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp O Valko
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Majidi S, Luby M, Lynch JK, Hsia AW, Benson RT, Kalaria CP, Nadareishvili Z, Latour LL, Leigh R. MRI-based thrombolytic therapy in patients with acute ischemic stroke presenting with a low NIHSS. Neurology 2019; 93:e1507-e1513. [PMID: 31519779 DOI: 10.1212/wnl.0000000000008312] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 05/16/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Treatment of patients with stroke presenting with minor deficits remains controversial, and the recent Potential of rtPA for Ischemic Strokes with Mild Symptoms (PRISMS) trial, which randomized patients to thrombolysis vs aspirin, did not show benefit. We studied the safety and efficacy of thrombolysis in a population of patients with acute stroke presenting with low NIH Stroke Scale (NIHSS) scores screened using MRI. METHODS The NIH Natural History of Stroke database was reviewed from January 2006 to December 2016 to identify all patients with an initial NIHSS score ≤5 who received thrombolysis within 4.5 hours of symptom onset after being screened with MRI. The 24-hour postthrombolysis MRIs were reviewed for hemorrhagic transformation. Primary outcomes were symptomatic intracranial hemorrhage (sICH) and favorable 90-day outcome modified Rankin Scale score 0-1. Subgroup analysis was performed on patients who would have been eligible for the PRISMS trial, which enrolled patients with a nondisabling neurologic deficit. RESULTS A total of 121 patients were included in the study with a median age of 65 and an NIHSS score of 3; 63% were women. The rate of any hemorrhagic transformation was 13%, with 11% of them being limited to petechial hemorrhage. The rate of sICH was <1%. Sixty-six patients had 90-day outcome data; of those, 74% had a favorable outcome. For the subgroup of 81 PRISMS-eligible patients, none experienced sICH. Fifty of these patients had 90-day outcome data; of these, 84% had a favorable outcome. CONCLUSIONS Thrombolytic therapy was safe in our patients with stroke with minor deficits who were initially evaluated by MRI. Future studies of this population may benefit from MRI selection. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with acute ischemic stroke and NIHSS ≤5 screened with MRI, IV tissue plasminogen activator is safe.
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Affiliation(s)
- Shahram Majidi
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Marie Luby
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - John K Lynch
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Amie W Hsia
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Richard T Benson
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Chandni P Kalaria
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Zurab Nadareishvili
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Lawrence L Latour
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Richard Leigh
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD.
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Ren Z, Mokin M, Bauer CT, Miao Z, Burgin WS, Wang Y. Indications for Mechanical Thrombectomy—Too Wide or Too Narrow? World Neurosurg 2019; 127:492-499. [DOI: 10.1016/j.wneu.2019.04.116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 10/27/2022]
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Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Heldner MR, Kurmann CC, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Pereira VM, Gralla J, Fischer U. Clinical effect of successful reperfusion in patients presenting with NIHSS < 8: data from the BEYOND-SWIFT registry. J Neurol 2019; 266:598-608. [PMID: 30617997 PMCID: PMC6394689 DOI: 10.1007/s00415-018-09172-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/22/2018] [Accepted: 12/25/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE If patients presenting with large vessel occlusions (LVO) and mild symptoms should be treated with endvoascular treatment (EVT) remains unclear. Aims of this study were (1) assessing the safety and technical efficacy of EVT in patients with NIHSS < 8 as opposed to a comparison group of patients presenting with NIHSS ≥ 8 and (2) evaluation of the clinical effect of reperfusion in patients with NIHSS < 8. METHODS Patients included into the retrospective multicenter BEYOND-SWIFT registry (NCT03496064) were analyzed. Clinical effect of achieving successful reperfusion (defined as modified Thrombolysis in Cerebral Infarction grade 2b/3) in patients presenting with NIHSS < 8 (N = 193) was evaluated using multivariable logistic regression analyses (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI). Primary outcome was excellent functional outcome (modified Rankin Scale, mRS 0-1) at day 90. Safety and efficacy of mechanical thrombectomy in patients with NIHSS < 8 was compared to patients presenting with NIHSS ≥ 8 (N = 1423). RESULTS Among patients with NIHSS < 8 (N = 193, 77/193, 39.9% receiving pre-interventional IV-tPA), successful reperfusion was significantly related to mRS 0-1 (aOR 3.217, 95%-CI 1.174-8.816) and reduced the chances of non-hemorrhagic neurological worsening (aOR 0.194, 95%-CI 0.050-0.756) after adjusting for prespecified confounders. In interaction analyses, the relative merits of achieving successful reperfusion were mostly comparable between patients presenting with NIHSS < 8 and NIHSS ≥ 8 as evidenced by non-significantly different aOR. Interventional safety and efficacy metrics were similar between patients with NIHSS < 8 and NIHSS ≥ 8. CONCLUSIONS Achieving successful reperfusion is beneficial in patients with persisting LVO presenting with NIHSS < 8 and reduces the risk of non-hemorrhagic neurological worsening.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Panagiotis Chaloulos-Iakovidis
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Leonidas Panos
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Christoph C Kurmann
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Radiology, CHUV Lausanne, Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | | | | | - Joanna Schaafsma
- Department of Neurology, Toronto Western Hospital, Toronto, ON, Canada
| | - Vitor Mendes Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
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48
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Koge J. [Reperfusion therapy in patients with minor or mild ischemic stroke]. Rinsho Shinkeigaku 2019; 59:84-92. [PMID: 30700691 DOI: 10.5692/clinicalneurol.cn-001255] [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: 11/05/2022]
Abstract
A significant number of patients with minor or mild stroke symptoms on initial presentation subsequently develop neurological deterioration and poor clinical outcomes at hospital discharge. The presence of an underlying large vessel occlusion is a strong predictor of both clinical worsening and poor outcome. Although patients with a low baseline National Institutes of Health Stroke Scale (NIHSS) could have been included in some randomized controlled trials, the benefits of the mechanical thrombectomy for patients with a low NIHSS score are unknown. The causes of neurological deterioration in patients with underlying large vessel occlusion are heterogeneous, but include collateral failure, and no straightforward mechanisms are found in the majority of cases. Patients with internal carotid artery occlusion, but with a patent middle cerebral artery (MCA), can occasionally have good collateral circulation and develop only minor or mild stroke. These patients exhibit collateral MCA flow via the circle of Willis despite ipsilateral internal carotid artery occlusion. However, thrombus migration may cause occlusion of collateral MCA flow, leading to dramatic neurological deterioration. Careful observation and detailed assessment are required for the management of these patients. Recent studies have examined the efficacy and optimal timing of thrombolysis or mechanical thrombectomy for patients with minor or mild stroke. Herein, we review the mechanisms of neurological deterioration, and the efficacy of reperfusion therapy, for patients with minor or mild stroke.
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Affiliation(s)
- Junpei Koge
- Division of Neurology, Saiseikai Fukuoka General Hospital
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49
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Naess H, Thomassen L, Waje-Andreassen U, Glad S, Kvistad CE. High risk of early neurological worsening of lacunar infarction. Acta Neurol Scand 2019; 139:143-149. [PMID: 30229856 DOI: 10.1111/ane.13029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/27/2018] [Accepted: 09/12/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate factors associated with neurological worsening among patients with lacunar or non-lacunar infarction admitted within 3 hours and between 3 and 24 hours after stroke onset. METHODS All patients admitted to Haukeland university hospital between 2006 and 2016 with acute cerebral infarction on MRI and admission within 24 hours were included. Repeated National Institute of Health Stroke Scale (NIHSS) scoring was performed in all patients whenever possible. Neurological worsening during the hospital stay was defined as NIHSS score increase ≥3 compared to NIHSS score on admission. RESULTS In patients with lacunar infarction admitted within 3 hours of onset, neurological worsening was associated with low NIHSS score on admission, low body temperature, and leukoaraiosis, whereas only internal carotid artery stenosis or occlusion was associated with neurological worsening in non-lacunar infraction. For patients admitted 3-24 hours after onset, neurological worsening was associated with low body temperature, high systolic blood pressure, and short time from onset to admission in patients with lacunar infarction, whereas high systolic blood pressure, high NIHSS score on admission, middle cerebral artery occlusion, and high blood glucose were associated with neurological worsening in patients with non-lacunar infarction (all P < 0.05). CONCLUSIONS Lacunar infarctions with minor neurological deficits within 3 hours of stroke onset are at high risk of neurological worsening especially if concomitant low body temperature and leukoaraiosis.
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Affiliation(s)
- Halvor Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Centre for age-related medicine; Stavanger University Hospital; Stavanger Norway
| | - Lars Thomassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Ulrike Waje-Andreassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Solveig Glad
- Department of Neurology; Haukeland University Hospital; Bergen Norway
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50
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Da Ros V, Cortese J, Chassin O, Rouchaud A, Sarov M, Caroff J, Mihalea C, Minosse S, Taifas I, Scaggiante J, Greco L, Ikka L, Ben Achour N, Di Giuliano F, Ozanne A, Legris N, Diomedi M, Sallustio F, Floris R, Denier C, Spelle L. Thrombectomy or intravenous thrombolysis in patients with NIHSS of 5 or less? J Neuroradiol 2019; 46:225-230. [PMID: 30659890 DOI: 10.1016/j.neurad.2019.01.089] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND PURPOSE To compare outcomes of minor stroke patients with intracranial vessel occlusions (IVO) underwent mechanical thrombectomy (MT) versus those treated with intravenous thrombolysis alone (IVT). METHODS We retrospectively reviewed two large prospective stroke databases from two European centers searching for patients admitted with minor stroke (i.e. NIHSS Score░≤░5), baseline mRS░=░0 and occlusion of the M1-M2 segment of the middle cerebral artery (MCA). Groups receiving (A) IVT alone and (B) MT+/-IVT were compared. Primary outcome measures were MT safety, successful recanalization rate (mTICI 2b-3) and NIHSS shift (discharge NIHSS minus admission NIHSS); secondary outcomes included discharge rates and excellent outcome (mRS 0-1) at 3 months. Univariate and multivariate analyses were performed. RESULTS Thirty-two patients were enrolled in Group B (19░MT alone; 13 MT░+░IVT) and 24 in Group A. Successful recanalization (mTICI 2b-3) was obtained in 100% of cases in Group B vs 38% in Group A. Symptomatic hemorrhagic transformation rate did not differ between the two groups. Multivariate analysis reported MT as the only predictor of early (<░12░h) favorable NIHSS shift and lower NIHSS at discharge. Moreover, discharge at home and excellent outcome at 3-month follow-up were statistically associated with MT. CONCLUSIONS MT in patients with minor strokes and intracranial vessel occlusion (IVO) is safe and can determine a rapid improvement of NIHSS Score. MT seems also associated with a higher rate of patients discharged at home after hospitalization and better clinical outcome at 3-month follow-up. Larger randomized trials are warranted to confirm these results.
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Affiliation(s)
- Valerio Da Ros
- Department of diagnostic imaging and interventional radiology, "Tor Vergata" university Hospital, viale Oxford, 81, 00133 Rome, Italy; Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France.
| | - Jonathan Cortese
- Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Olivier Chassin
- Department of Neurology, Bicêtre Hospital, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, Paris, France
| | - Aymeric Rouchaud
- Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Mariana Sarov
- Department of Neurology, Bicêtre Hospital, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, Paris, France
| | - Jildaz Caroff
- Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Cristian Mihalea
- Department of diagnostic imaging and interventional radiology, "Tor Vergata" university Hospital, viale Oxford, 81, 00133 Rome, Italy; Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Silvia Minosse
- Department of diagnostic imaging and interventional radiology, "Tor Vergata" university Hospital, viale Oxford, 81, 00133 Rome, Italy
| | - Irina Taifas
- Department of Neurology, Bicêtre Hospital, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, Paris, France
| | - Jacopo Scaggiante
- Department of diagnostic imaging and interventional radiology, "Tor Vergata" university Hospital, viale Oxford, 81, 00133 Rome, Italy
| | - Laura Greco
- Department of diagnostic imaging and interventional radiology, "Tor Vergata" university Hospital, viale Oxford, 81, 00133 Rome, Italy
| | - Leon Ikka
- Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Nidhal Ben Achour
- Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Francesca Di Giuliano
- Department of diagnostic imaging and interventional radiology, "Tor Vergata" university Hospital, viale Oxford, 81, 00133 Rome, Italy
| | - Augustin Ozanne
- Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France
| | - Nicolas Legris
- Department of Neurology, Bicêtre Hospital, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, Paris, France
| | - Marina Diomedi
- Department of Neurology, Stroke Unit, "Tor Vergata" University Hospital, viale Oxford, 81, 00133 Rome, Italy
| | - Fabrizio Sallustio
- Department of Neurology, Stroke Unit, "Tor Vergata" University Hospital, viale Oxford, 81, 00133 Rome, Italy
| | - Roberto Floris
- Department of diagnostic imaging and interventional radiology, "Tor Vergata" university Hospital, viale Oxford, 81, 00133 Rome, Italy
| | - Christian Denier
- Department of Neurology, Bicêtre Hospital, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, Paris, France
| | - Laurent Spelle
- Interventional Neuroradiology NEURI Center, Hôpital Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin Bicêtre, France
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