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Rodriguez Calienes A, Galecio-Castillo M, Petersen NH, Ribo M, Farooqui M, Hassan AE, Jumaa MA, Divani AA, Abraham MG, Fifi JT, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Sheth S, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Lu Y, Vivanco-Suarez J, Dibas M, Mokin M, Yavagal DR, Jovin TG, Ortega-Gutierrez S. Mediation Analysis of Acute Carotid Stenting in Tandem Lesions: Effect on Functional Outcome in a Multicenter Registry. Neurology 2024; 103:e209617. [PMID: 38959444 DOI: 10.1212/wnl.0000000000209617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Current evidence suggests that acute carotid artery stenting (CAS) for cervical lesions is associated with better functional outcomes in patients with acute stroke with tandem lesions (TLs) treated with endovascular therapy (EVT). However, the underlying causal pathophysiologic mechanism of this relationship compared with a non-CAS strategy remains unclear. We aimed to determine whether, and to what degree, reperfusion mediates the relationship between acute CAS and functional outcome in patients with TLs. METHODS This subanalysis stems from a multicenter retrospective cohort study across 16 stroke centers from January 2015 to December 2020. Patients with anterior circulation TLs who underwent EVT were included. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale ≥2B by the local team at each participating center. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and functional outcome (90-day modified Rankin Scale) is mediated by successful reperfusion. RESULTS A total of 570 patients were included, with a median age (interquartile range) of 68 (59-76), among whom 180 (31.6%) were female. Among these patients, 354 (62.1%) underwent acute CAS and 244 (47.4%) had a favorable functional outcome. The remaining 216 (37.9%) patients were in the non-CAS group. The CAS group had significantly higher rates of successful reperfusion (91.2% vs 85.1%; p = 0.025) and favorable functional outcomes (52% vs 29%; p = 0.003) compared with the non-CAS group. Successful reperfusion was a strong predictor of functional outcome (adjusted common odds ratio [acOR] 4.88; 95% CI 2.91-8.17; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS remained significantly associated with functional outcome after adjustment for successful reperfusion (acOR 1.89; 95% CI 1.27-2.83; p = 0.002). Successful reperfusion explained 25% (95% CI 3%-67%) of the relationship between acute CAS and functional outcome. DISCUSSION In patients with TL undergoing EVT, successful reperfusion predicted favorable functional outcomes when CAS was performed compared with non-CAS. A considerable proportion (25%) of the treatment effect of acute CAS on functional outcome was found to be mediated by improvement of successful reperfusion rates.
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Affiliation(s)
- Aaron Rodriguez Calienes
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Milagros Galecio-Castillo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Nils H Petersen
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Marc Ribo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mudassir Farooqui
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Ameer E Hassan
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mouhammad A Jumaa
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Afshin A Divani
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Michael G Abraham
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Johanna T Fifi
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Waldo R Guerrero
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Amer M Malik
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - James E Siegler
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Thanh N Nguyen
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Sunil Sheth
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Albert J Yoo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Guillermo Linares
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Nazli Janjua
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Darko Quispe-Orozco
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Yujing Lu
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Juan Vivanco-Suarez
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mahmoud Dibas
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Maxim Mokin
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Dileep R Yavagal
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Tudor G Jovin
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Santiago Ortega-Gutierrez
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
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Cucchiara B, Majersik JJ. The Case of Anticoagulation for Progressing Stroke: Have We Come Full Circle? JAMA Neurol 2024; 81:113-114. [PMID: 38190153 DOI: 10.1001/jamaneurol.2023.5086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Affiliation(s)
- Brett Cucchiara
- Department of Neurology, University of Pennsylvania, Philadelphia
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Elhefnawy M, Nazifah Sidek N, Maisharah Sheikh Ghadzi S, Ibrahim B, Looi I, Abdul Aziz Z, Noor Harun S. Prevalence of Stroke-Associated Pneumonia and Its Predictors Among Hyperglycaemia Patients During Acute Ischemic Stroke. Cureus 2024; 16:e52574. [PMID: 38371076 PMCID: PMC10874618 DOI: 10.7759/cureus.52574] [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: 01/19/2024] [Indexed: 02/20/2024] Open
Abstract
BACKGROUND Hyperglycaemia (HG) during an acute ischemic stroke (AIS) is not only associated with unfavourable functional outcomes but also associated with stroke-associated pneumonia (SAP). This study aimed to determine the prevalence of SAP among Malaysian patients with AIS and the predictors of SAP among patients with HG during AIS. METHODS This is a retrospective cross-sectional study that included patients with AIS admitted to Hospital Sultanah Nur Zahirah, Malaysia from 2017 to 2020. SAP was defined as infection with pneumonia during the first seven days after IS. HG was defined as a blood glucose level > 7.8 mmol/L within 72 h after admission. Patients with SAP were divided into two groups according to HG status. Multivariate logistic regression analysis was performed using SPSS software, version 22 (IBM Corp., Armonk, NY) to identify SAP predictors among patients with HG. Kaplan-Meier log-rank test was used to compare the survival rate from unfavourable functional outcomes between hyperglycaemic patients with and without SAP. RESULTS Among 412 patients with AIS, 69 (16.74%) had SAP. The prevalence of SAP among patients with HG and normoglycemia during AIS was 20.98%, and 10.65%, respectively. Age above 60 years, leucocytosis, and National Institute of Health Stroke Scale (NIHSS) > 14 on admission were independent predictors of SAP with aOR of 2.08 (95% CI;1.01-4.30), 2.83 (95% CI; 1.41-5.67), and 3.67 (95% CI; 1.53-8.80), respectively. No significant difference in unfavourable functional outcomes survival was found among patients with and without SAP (p = 0.653). CONCLUSION This study demonstrated the prevalence of SAP was higher among patients with HG compared to normoglycemia during AIS. The patient being old, leucocytosis and severe stroke upon admission predict the occurrence of SAP among patients with HG during AIS.
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Affiliation(s)
- Marwa Elhefnawy
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MYS
| | | | | | | | - Irene Looi
- Clinical Research Centre, Hospital Seberang Jaya, Seberang Jaya, MYS
| | - Zariah Abdul Aziz
- Clinical Research Centre, Hospital Sultanah Nur Zahirah, Terengganu, MYS
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Găman MA, Cozma MA, Manan MR, Srichawla BS, Dhali A, Ali S, Nahian A, Elton AC, Simhachalam Kutikuppala LV, Suteja RC, Diebel S, Găman AM, Diaconu CC. Budd-Chiari syndrome in myeloproliferative neoplasms: A review of literature. World J Clin Oncol 2023; 14:99-116. [PMID: 37009527 PMCID: PMC10052333 DOI: 10.5306/wjco.v14.i3.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/10/2023] [Accepted: 03/01/2023] [Indexed: 03/19/2023] Open
Abstract
Myeloproliferative neoplasms (MPNs) are defined as clonal disorders of the hematopoietic stem cell in which an exaggerated production of terminally differentiated myeloid cells occurs. Classical, Philadelphia-negative MPNs, i.e., polycythemia vera, essential thrombocythemia and primary myelofibrosis, exhibit a propensity towards the development of thrombotic complications that can occur in unusual sites, e.g., portal, splanchnic or hepatic veins, the placenta or cerebral sinuses. The pathogenesis of thrombotic events in MPNs is complex and requires an intricate mechanism involving endothelial injury, stasis, elevated leukocyte adhesion, integrins, neutrophil extracellular traps, somatic mutations (e.g., the V617F point mutation in the JAK2 gene), microparticles, circulating endothelial cells, and other factors, to name a few. Herein, we review the available data on Budd-Chiari syndrome in Philadelphia-negative MPNs, with a particular focus on its epidemiology, pathogenesis, histopathology, risk factors, classification, clinical presentation, diagnosis, and management.
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Affiliation(s)
- Mihnea-Alexandru Găman
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest 050474, Romania
- Department of Hematology, Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Matei-Alexandru Cozma
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest 050474, Romania
| | | | - Bahadar S Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts 01655, United States
| | - Arkadeep Dhali
- Department of Internal Medicine, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, United Kingdom
| | - Sajjad Ali
- Department of Medicine, Ziauddin University, Karachi 75600, Pakistan
| | - Ahmed Nahian
- California Baptist University-Lake Erie College of Osteopathic Medicine, Riverside, CA 92504, United States
| | - Andrew C Elton
- University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - L V Simhachalam Kutikuppala
- Department of General Surgery, Dr NTR University of Health Sciences, Andhra Pradesh, Vijayawada 520008, India
| | - Richard Christian Suteja
- Department of Undergraduate Medicine, Faculty of Medicine, Udayana University Denpasar, Bali 80232, Indonesia
| | - Sebastian Diebel
- Department of Family Medicine, Northern Ontario School of Medicine Timmins, Ontario 91762, Canada
| | - Amelia Maria Găman
- Department of Pathophysiology, University of Medicine and Pharmacy of Craiova, Romania & Clinic of Hematology, Filantropia City Hospital, Craiova 200143, Romania
| | - Camelia Cristina Diaconu
- Department of Internal Medicine, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Romania & Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, Bucharest 105402, Romania
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Perioperative Medical Management for Symptomatic Carotid Artery Interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mechanical thrombectomy via chronic occluded proximal artery for the endovascular treatment of acute ischemic stroke patients with large vessel occlusion. J Clin Neurosci 2022; 99:130-136. [PMID: 35279585 DOI: 10.1016/j.jocn.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 12/31/2021] [Accepted: 01/11/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) can significantly improve the prognosis of acute ischemic stroke patients with large vessel occlusion. However, for patients with chronic occluded proximal artery, therapeutical strategies are limited because the endovascular route for MT is not readily accessible. METHODS Here, we introduce a safe and effective MT procedure via a chronic occluded proximal artery. We conducted a retrospective study of seven patients with acute ischemic stroke due to large artery occlusion (AIS-LVO) who underwent MT via a chronic occluded proximal artery for endovascular treatment. We analyzed the technical procedure of the MT and the clinical outcomes of these patients. RESULTS The distal thrombus was successfully removed in all patients by opening the occluded proximal artery, thus achieving revascularization with a Thrombolysis in Cerebral Infarction (TICI) of 2b/3. The average time from arterial puncture to reperfusion was 171.14 ± 36.56 min. Three patients had a good modified Rankin scale (mRS) score (0-2) at discharge. Among 4 patients with anterior circulation stroke, 2 recovered completely, 1 had anomic aphasia, and 1 had hemiplegia. Among 3 patients with posterior circulation stroke, 1 recovered completely, 1 had locked-in syndrome, and 1 was comatose. Four patients had good functional prognoses. CONCLUSIONS Mechanical thrombectomy procedure via a chronic occluded proximal artery can be used in patients with well-established collateral compensatory vessels. It is safe and effective in improving the prognosis of patients. It can be used as a remedial treatment strategy for patients with AIS-LVO.
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Martinez-Gutierrez JC, Roy AT, D'Amato S, Berkman JM, Montes D, Kimball CA, Rordorf GA, Chibnik LB, Romero JM, Silverman SB. Preoperative antithrombotic treatment in acutely symptomatic carotid artery stenosis. J Stroke Cerebrovasc Dis 2022; 31:106396. [PMID: 35219972 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Early recurrence of cerebral ischemia in acutely symptomatic carotid artery stenosis can precede revascularization. The optimal antithrombotic regimen for this high-risk population is not well established. Although antiplatelet agents are commonly used, there is limited evidence for the use of anticoagulants. We sought to understand the safety and efficacy of short-term preoperative anticoagulants in secondary prevention of recurrent cerebral ischemic events from acutely symptomatic carotid stenosis in patients awaiting carotid endarterectomy (CEA). MATERIALS AND METHODS A retrospective query of a prospective single institution registry of carotid revascularization was performed. Patients who presented with acute ischemic stroke or transient ischemic attack (TIA) attributable to an ipsilateral internal carotid artery stenosis (ICA) were included. Antiplatelet (AP) only and anticoagulation (AC) treatment arms were compared. The primary outcome was a composite of preoperative recurrent ischemic stroke or TIA. The primary safety outcome was symptomatic intracranial hemorrhage. RESULTS Out of 443 CEA patients, 342 were in the AC group and 101 in the AP group. Baseline characteristics between groups (AC vs AP) were similar apart from age (71±10.5 vs 73±9.5, p=0.04), premorbid modified Rankin scale (mRS) score (1.0±1.2 vs 1.4±1.3, p=0.03) and stroke as presenting symptom (65.8 vs 53.5%, p=0.02). Patients in the AC group had a lower incidence of recurrent stroke/TIA (3.8 vs 10.9%, p=0.006). One patient had symptomatic intracranial hemorrhage in the AC group, and none in the AP group. In multivariate analysis controlling for age, premorbid mRS, stroke severity, degree of stenosis, presence of intraluminal thrombus (ILT) and time to surgery, AC was protective (OR 0.30, p=0.007). This effect persisted in the cohort exclusively without ILT (OR 0.23, p=0.002). CONCLUSIONS Short term preoperative anticoagulation in patients with acutely symptomatic carotid stenosis appears safe and effective compared to antiplatelet agents alone in the prevention of recurrent cerebral ischemic events while awaiting CEA.
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Affiliation(s)
- Juan Carlos Martinez-Gutierrez
- Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
| | - Alexis T Roy
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Salvatore D'Amato
- Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Jillian M Berkman
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Daniel Montes
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Cheryl A Kimball
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Guy A Rordorf
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Lori B Chibnik
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Javier M Romero
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
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8
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Cirillo L, Romano DG, Vornetti G, Frauenfelder G, Tamburrano C, Taglialatela F, Isceri S, Saponiero R, Napoletano R, Gentile M, Romoli M, Princiotta C, Simonetti L, Zini A. Acute ischemic stroke with cervical internal carotid artery steno-occlusive lesion: multicenter analysis of endovascular approaches. BMC Neurol 2021; 21:362. [PMID: 34535118 PMCID: PMC8447719 DOI: 10.1186/s12883-021-02393-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occlusion of the internal carotid artery (ICA), whether isolated or in the setting of a tandem lesion (TL) have a poor response to treatment with intravenous thrombolysis. Previous studies have demonstrated the superiority of mechanical thrombectomy in the treatment of acute ischemic stroke (AIS) following large vessel occlusion, compared to standard intravenous fibrinolysis. The aim of our study was to describe endovascular treatment (EVT) in AIS due to isolated ICA occlusion or TL. METHODS We assessed the association between 90-day outcome and clinical, demographic, imaging, and procedure data in 51 consecutive patients with acute isolated ICA occlusion or TL who underwent EVT. We evaluated baseline NIHSS and mRS, ASPECTS, type of occlusion, stent placement, use of stent retrievers and/or thromboaspiration, duration of the procedure, mTICI, postprocedural therapy and complications. RESULTS A favorable 90-day outcome (mRS 0-2) was achieved in 34 patients (67 %) and was significantly associated with the use of dual antiplatelet therapy after the procedure (p = 0.008), shorter procedure duration (p = 0.031), TICI 2b-3 (p < 0.001) and lack of post-procedural hemorrhagic transformation (p = 0.001). Four patients did not survive, resulting in a mortality rate of 8 %. CONCLUSIONS Our study has shown that EVT in the treatment of AIS due to ICA occlusion is safe, and effective in determining a good functional outcome. ICA stenting led to good angiographic results and therapy with a glycoprotein IIb / IIIa inhibitor immediately after stent release did not result in a greater risk of hemorrhage. The use of post-procedural dual antiplatelet therapy was associated with favorable outcome, without a significant increase in hemorrhagic transformation.
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Affiliation(s)
- Luigi Cirillo
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy. .,UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy.
| | | | - Gianfranco Vornetti
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy
| | - Giulia Frauenfelder
- UOC Neuroradiologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Chiara Tamburrano
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy
| | - Francesco Taglialatela
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Salvatore Isceri
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Renato Saponiero
- UOC Neuroradiologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Rosa Napoletano
- UOC Neurologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Mauro Gentile
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Michele Romoli
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Ciro Princiotta
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Luigi Simonetti
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Zini
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
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9
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Han M, Seo K, Choi J. Cervical Vascular Diseases Rarely Observed by Duplex Sonography: 3 Cases. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2021. [DOI: 10.15324/kjcls.2021.53.1.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Minho Han
- Department of Neurology, Severance Hospital, Yonsei University Health System, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Kangsik Seo
- Department of Neurology, Severance Hospital, Yonsei University Health System, Seoul, Korea
| | - Junghye Choi
- Department of Neurology, Severance Hospital, Yonsei University Health System, Seoul, Korea
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10
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Azzabi Zouraq S, Bouchal S, Haloua M, Alami B, Boubbou M, Maaroufi M, Alaoui Lamrani MY. Permanent cervical carotid occlusion with coils as an endovascular management of tandem carotid lesions in acute ischemic stroke. JOURNAL DE MÉDECINE VASCULAIRE 2021; 46:93-96. [PMID: 33752852 DOI: 10.1016/j.jdmv.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Affiliation(s)
- S Azzabi Zouraq
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco.
| | - S Bouchal
- Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Department of Neurology, CHU de Hassan II de Fès, Fès, Morocco
| | - M Haloua
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| | - B Alami
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| | - M Boubbou
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| | - M Maaroufi
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| | - M Y Alaoui Lamrani
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
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11
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Symptomatic isolated internal carotid artery occlusion with initial medical management: a monocentric cohort. J Neurol 2020; 268:346-355. [PMID: 32809152 DOI: 10.1007/s00415-020-10118-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Symptomatic isolated carotid artery occlusions (ICAO) can lead to disability, recurrent stroke, and mortality, but natural history and best therapeutic management remain poorly known. The objective of this study was to describe our cohort of ICAO patients with an initial medical management. METHODS We conducted a retrospective study including consecutive patients admitted to our Comprehensive Stroke Center for ICAO within 24 h after stroke onset between January 2016 and September 2018. Patients with immediate endovascular therapy (EVT) were excluded. Medical treatment was based on anticoagulation (delayed by 24 h if intravenous thrombolysis was performed). 'Rescue' EVT was considered if first-week neurological deterioration (FWND) occurred. RESULTS Fifty-six patients were included, with a median National Institutes of Health Stroke Scale (NIHSS) of 3. Eleven patients (20%) had FWND during the first week, four benefited from rescue EVT. A mismatch volume > 40 cc on initial perfusion imaging and FLAIR vascular hyperintensities were associated with FWND (p = 0.007 and p = 0.009, respectively). Thirty-eight patients (69%) had a good outcome (modified Rankin Scale mRS 0-2) at 3 months, 36 (69%) had an excellent outcome (mRS 0-1). Seventeen patients (38%) had carotid patency on 3-month control imaging. Recurrences occurred in six (13%) of the survivors (mean follow-up: 13.6 months). CONCLUSION Our results suggest that the prognosis of patients with acute ICAO was favorable with a medical strategy, albeit a substantial rate of FWND and recurrence. FWND was well predicted by a core-perfusion mismatch volume > 40 cc. Randomized controlled trials are necessary to assess the benefit of EVT in ICAO.
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12
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Moon GI, Baek BH, Kim SK, Lee YY, Lee HJ, Yoon W. Predictors of a Favorable Outcome after Emergent Carotid Artery Stenting in Acute Anterior Circulation Stroke Patients. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:665-675. [PMID: 36238632 PMCID: PMC9431905 DOI: 10.3348/jksr.2020.81.3.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/09/2019] [Accepted: 09/14/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Gyeong Il Moon
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Byung Hyun Baek
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Seul Kee Kim
- Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yun Young Lee
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Hyo-Jae Lee
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Woong Yoon
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
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13
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Han TS, Fry CH, Gulli G, Affley B, Robin J, Irvin-Sellers M, Fluck D, Kakar P, Sharma S, Sharma P. Prestroke Disability Predicts Adverse Poststroke Outcome: A Registry-Based Prospective Cohort Study of Acute Stroke. Stroke 2019; 51:594-600. [PMID: 31842700 DOI: 10.1161/strokeaha.119.027740] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Information on what effect disability before stroke can have on stroke outcome is lacking. We assessed prestroke disability in relation to poststroke hospital outcome. Methods- Analysis of prospectively collected data from the Sentinel Stroke National Audit Programme. A total of 1656 men (mean age ±SD =73.1±13.2 years) and 1653 women (79.3±13.0 years) were admitted to hyperacute stroke units with acute stroke in 4 major UK between 2014 and 2016. Prestroke disability, assessed by modified Rankin Scale (mRS), was tested against poststroke adverse outcomes, adjusted for age, sex, and coexisting morbidities. Results- Compared with patients with prestroke mRS score =0, individuals with prestroke mRS scores =3, 4, or 5 had greater adjusted risks of moderately severe or severe stroke on arrival (4.4% versus 16.7%; odds ratio [OR], 3.2 [95% CI, 2.3-4.6] P<0.001); urinary tract infection or pneumonia within 7 days of admission (9.6% versus 35.9%; OR, 3.7 [95% CI, 2.8-4.8] P<0.001); mortality (7.2% versus 37.1%; OR, 4.9 [95% CI, 3.7-6.5] P<0.001); requiring help with activities of daily living on discharge (12.3% versus 26.7%; OR, 3.1 [95% CI, 2.3-4.1] P<0.001); and transferred to new care home (2.4% versus 9.4%; OR, 2.1 [95% CI, 1.3-3.3] P=0.002). Patients with mRS scores =1 or 2 had intermediate risk of adverse outcomes. Overall, those with a mRS score =1 or 2 had length of stay on hyperacute stroke units extended by 5.3 days (95% CI, 2.8-7.7; P<0.001) and mRS score =3, 4 or 5 by 7.2 days (95% CI, 4.0-10.5; P<0.001). Conclusions- Individuals with evidence of prestroke disability, assessed by mRS, had significantly increased risk of poststroke adverse outcomes and longer length of stay on hyperacute stroke units and higher level of care on discharge.
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Affiliation(s)
- Thang S Han
- From the Institute of Cardiovascular Research, Royal Holloway University of London, Egham, United Kingdom (T.S.H., S.S., P.S.)
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, United Kingdom (C.H.F.)
| | - Giosue Gulli
- Department of Stroke (B.A., G.G.), Ashford and St Peter's NHS Foundation Trust, Chertsey, United Kingdom
| | - Brendan Affley
- Department of Stroke (B.A., G.G.), Ashford and St Peter's NHS Foundation Trust, Chertsey, United Kingdom
| | - Jonathan Robin
- Department of Medicine (J.R., M.I.-S.), Ashford and St Peter's NHS Foundation Trust, Chertsey, United Kingdom
| | - Melanie Irvin-Sellers
- Department of Medicine (J.R., M.I.-S.), Ashford and St Peter's NHS Foundation Trust, Chertsey, United Kingdom
| | - David Fluck
- Department of Cardiology (D.F.), Ashford and St Peter's NHS Foundation Trust, Chertsey, United Kingdom
| | - Puneet Kakar
- Department of Stroke, Epsom and St Helier University Hospitals, United Kingdom (P.K.)
| | - Sapna Sharma
- From the Institute of Cardiovascular Research, Royal Holloway University of London, Egham, United Kingdom (T.S.H., S.S., P.S.)
| | - Pankaj Sharma
- From the Institute of Cardiovascular Research, Royal Holloway University of London, Egham, United Kingdom (T.S.H., S.S., P.S.).,Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London, United Kingdom (P.S.)
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14
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Abstract
PURPOSE OF REVIEW Ischemic stroke describes a condition in which inadequate blood flow leads to lack of oxygenation to the brain tissue and ensuing neuronal death. There are multiple causes of ischemic stroke, each of which may indicate different antithrombotic management strategies. The goal of this review is to provide information about antithrombotic therapies for secondary stroke prevention based on etiology of stroke. RECENT FINDINGS New studies of existing antiplatelet and antithrombotic therapies have demonstrated varied efficacies of treatments based on the underlying risk factor of ischemic stroke. Understanding the optimal therapies for secondary stroke prevention can enhance care of stroke patients and lower the incidence of recurrent cerebrovascular ischemia.
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15
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Endovascular Recanalization of Acute Tandem Cervical Carotid and Intracranial Occlusions: Efficacy of Cervical Balloon Angioplasty Alone Then Intracranial Target Recanalization Strategy. World Neurosurg 2019; 126:e1268-e1275. [DOI: 10.1016/j.wneu.2019.02.240] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/22/2022]
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16
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Rajput PS, Lamb JA, Fernández JÁ, Bai J, Pereira BR, Lei IF, Leung J, Griffin JH, Lyden PD. Neuroprotection and vasculoprotection using genetically targeted protease-ligands. Brain Res 2019; 1715:13-20. [PMID: 30880117 DOI: 10.1016/j.brainres.2019.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 03/05/2019] [Accepted: 03/13/2019] [Indexed: 12/26/2022]
Abstract
Thrombin and activated protein C (APC) are known coagulation factors that exhibit profound effects in brain by acting on the protease activated receptor (PAR). The wild type (WT) proteases appear to impact cell survival powerfully, and therapeutic forms of APC are under development. Engineered recombinant thrombin or APC were designed to separate their procoagulant or anticoagulant effects from their cytoprotective properties. We measured vascular disruption and neuronal degeneration after a standard rodent filament stroke model. For comparison to a robust anticoagulant, we used a GpIIb/IIIa inhibitor, GR144053. During 2 h MCAo both WT murine APC and its mutant, 5A-APC, significantly decreased neuronal death 30 min after reperfusion. During 4 h MCAo, only 5A-APC significantly protected neurons but both WT-APC and 5A-APC exacerbated vascular disruption during 4 h MCAo. Human APC mutants appeared to reduce 24 h neuronal injury significantly when given after 2 h delay after MCAo. In contrast, 24 h vascular damage was worsened by high doses of WT and mutant APCs, although only statistically significantly for high dose 3K3A-APC. Mutated thrombin worsened vascular damage significantly without affecting neuron damage. GR144053 failed to ameliorate vascular disruption or neuronal injury despite significant anticoagulation. Differential effects on neurons and the vasculature were demonstrated using wild-type and mutated proteases. The mutants murine 3K3A-APC and 5A-APC protected neurons in this rodent model but in high doses worsened vascular leakage. Cytoactive effects of plasma proteases may be separated from their coagulation effects. Further studies should explore impact of dose and timing on cytoactive and vasculoactive properties of these drugs.
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Affiliation(s)
- Padmesh S Rajput
- Department of Neurology, Cedars Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048, United States
| | - Jessica A Lamb
- Department of Neurology, Cedars Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048, United States
| | - Jose Á Fernández
- Department of Molecular Medicine, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA 92037, United States
| | - Jilin Bai
- Department of Neurology, Cedars Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048, United States
| | - Benedict R Pereira
- Department of Neurology, Cedars Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048, United States
| | - I-Farn Lei
- Department of Neurology, Cedars Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048, United States
| | - Jennifer Leung
- Department of Neurology, Cedars Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048, United States
| | - John H Griffin
- Department of Molecular Medicine, The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA 92037, United States
| | - Patrick D Lyden
- Department of Neurology, Cedars Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048, United States.
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17
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Abstract
Introduction Acute internal carotid artery occlusion is a devastating form of ischemic accident with significant morbidity and possible mortality. The “threatened hemisphere” is allowed limited access to collateral circulation further worsening the ischemic burden and the overall prognosis. Methods We present the details of a case of a 38-year-old woman who suffered from an ischemic stroke. The clinical course of which showed a hemodynamic dependence to preserve her neurological function, prompting the use of the phosphodiesterase inhibitor milrinone to maintain her neurological function. Result This case represents the first case in the literature in which a medical therapy is used to salvage brain tissue in the site of acute symptomatic large vessel occlusion. This has spared the patient from a potential significant morbidity and even mortality if a revascularization procedure had been attempted. Conclusion This innovative use of milrinone, if applied in more captured patients with internal carotid occlusion or those with reversible hemodynamic failure, would improve our understanding of the ischemic thresholds and cerebral vascular reserves and would improve the clinical outcome of this significant ischemic insult.
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18
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Yang D, Shi Z, Lin M, Zhou Z, Zi W, Wang H, Hao Y, Guo F, Liu W, Xu G, Xiong Y, Liu X. Endovascular retrograde approach may be a better option for acute tandem occlusions stroke. Interv Neuroradiol 2018; 25:194-201. [PMID: 30290710 DOI: 10.1177/1591019918805140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The endovascular treatment strategy for acute tandem occlusion stroke is challenging, and controversy exists regarding which lesion should be treated first. This study addresses the uncertainty regarding the priority choice for thrombectomy in acute anterior circulation tandem occlusion stroke. METHODS We analysed the clinical and angiographic data of tandem stroke patients who underwent interventional therapy from the endovAsCular Treatment of acUte Anterior circuLation ischaemic stroke (ACTUAL) registry. Recanalisation was assessed according to the modified thrombolysis in cerebral infarction score. Clinical outcome was evaluated at 90 days using the modified Rankin scale score. RESULTS Sixty tandem occlusion stroke patients were enrolled. Thirty-one (51.7%) patients received anterograde therapy, while 29 (48.3%) patients underwent the retrograde approach. Successful recanalisation (modified thrombolysis in cerebral infarction score 2b-3) occurred in 78.3% (47/60) of patients, and 50.0% (30/60) of patients achieved a modified Rankin scale score of 0-2 at 90 days. Patients undergoing the retrograde approach spent less time in distal occlusion recanalisation (125 (86-167) vs. 95 (74-122) minutes; P = 0.04) and achieved better functional outcomes at 90 days (69.0% (20/29) vs. 32.3% (10/31); P = 0.004) than patients who received anterograde therapy. The retrograde approach was associated with favourable clinical outcomes (odds ratio 0.21; 95% confidence interval 0.07-0.64; P = 0.006). CONCLUSION For acute tandem occlusion stroke, favourable outcomes were better in patients undergoing retrograde therapy than in patients who received the anterograde approach. Future randomised trials are warranted to determine the optimal treatment.
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Affiliation(s)
- Dong Yang
- 1 Department of Neurology, Jinling Hospital, Nanjing, China
| | - Zhonghua Shi
- 2 Department of Neurosurgery, The 101st Hospital of The People's Liberation Army, Wuxi, China
| | - Min Lin
- 3 Department of Neurology, Fuzhou General Hospital of Nanjing Military Region, Fuzhou, China
| | - Zhiming Zhou
- 4 Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Wenjie Zi
- 1 Department of Neurology, Jinling Hospital, Nanjing, China
| | - Huaiming Wang
- 1 Department of Neurology, Jinling Hospital, Nanjing, China.,5 Department of Neurology, The 89th Hospital of The People's Liberation Army, Weifang, China
| | - Yonggang Hao
- 1 Department of Neurology, Jinling Hospital, Nanjing, China.,6 Department of Neurology, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Fuqiang Guo
- 7 Department of Neurology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Wenhua Liu
- 8 Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Gelin Xu
- 1 Department of Neurology, Jinling Hospital, Nanjing, China
| | - Yunyun Xiong
- 1 Department of Neurology, Jinling Hospital, Nanjing, China
| | - Xinfeng Liu
- 1 Department of Neurology, Jinling Hospital, Nanjing, China
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19
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Pires Coelho A, Lobo M, Gouveia R, Silveira D, Campos J, Augusto R, Coelho N, Canedo A. Overview of evidence on emergency carotid stenting in patients with acute ischemic stroke due to tandem occlusions: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:693-702. [PMID: 29363895 DOI: 10.23736/s0021-9509.18.10312-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Endovascular intracranial thrombectomy (IT) has established itself as the standard of care in treating large-vessel anterior circulation acute ischemic stroke (AIS). However, internal carotid artery (ICA) stenosis/occlusion hampers distal access and controversy about simultaneous emergency ICA stenting ensues. The purpose of this review was to evaluate the safety of emergency ICA stenting in combination with IT for AIS with tandem occlusions. To our knowledge this is the first meta-analysis to evaluate emergency ICA stenting in tandem occlusions, combining results from studies with a control group. EVIDENCE ACQUISITION A meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. EVIDENCE SYNTHESIS A total of 649 potentially relevant articles were initially selected. After reviewing at title or abstract level, 87 articles were read in full and 23 were included. These studies recruited 1000 patients, 220 submitted to IT with no emergency ICA stenting and 780 to IT and emergency ICA stenting. Successful revascularization (Thrombolysis in cerebral infarction scale [TICI] ≥2b) was achieved in 48.6-100%. Good outcome (modified Rankin scale [mRS] ≤2) ranged from 18.2-100%. Symptomatic intracranial hemorrhage (sICH) ranged from 0-45.7% (overall N.=168; 17.2%). Mortality at 90 days ranged from 0-45.4% (overall N.=114; 11.7%). Time to recanalization was significantly longer in the stenting group with an overall mean difference of 1.76 (95% CI: 1.59-1.93). CONCLUSIONS In this meta-analysis time to recanalization was significantly longer in the emergency ICA stenting group. There was no benefit from emergency stenting in parameters such as successful revascularization (TICI≥2b), clinical outcome (mRS≤2) or 90-day mortality. Data on sICH were scarce. Emergency ICA stenting appears to increase time to revascularization and increase the risk of complications with no demonstrated clinical benefit. Furthermore, no prospective, randomized controlled trials demonstrating relative efficacy and safety of concomitant ICA stenting have been published to date. Additional studies must be undertaken to define the role of angioplasty and stenting of the extracranial carotid arteries in the early management of acute stroke in tandem occlusions. Until then, we recommend that ICA stenting concomitant to thrombectomy in acute stroke patients should be avoided.
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Affiliation(s)
- Andreia Pires Coelho
- Department of Angiology and Vascular Surgery, Hospital of Vila Nova de Gaia and Espinho, Porto, Portugal - .,Faculty of Medicine, University of Porto, Porto, Portugal -
| | - Miguel Lobo
- Department of Angiology and Vascular Surgery, Hospital of Vila Nova de Gaia and Espinho, Porto, Portugal
| | - Ricardo Gouveia
- Department of Angiology and Vascular Surgery, Hospital of Vila Nova de Gaia and Espinho, Porto, Portugal
| | - Diogo Silveira
- Department of Angiology and Vascular Surgery, Hospital of Vila Nova de Gaia and Espinho, Porto, Portugal
| | - Jacinta Campos
- Department of Angiology and Vascular Surgery, Hospital of Vila Nova de Gaia and Espinho, Porto, Portugal
| | - Rita Augusto
- Department of Angiology and Vascular Surgery, Hospital of Vila Nova de Gaia and Espinho, Porto, Portugal
| | - Nuno Coelho
- Department of Angiology and Vascular Surgery, Hospital of Vila Nova de Gaia and Espinho, Porto, Portugal
| | - Alexandra Canedo
- Department of Angiology and Vascular Surgery, Hospital of Vila Nova de Gaia and Espinho, Porto, Portugal
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Han TS, Fry CH, Fluck D, Affley B, Gulli G, Barrett C, Kakar P, Patel T, Sharma S, Sharma P. Evaluation of anticoagulation status for atrial fibrillation on early ischaemic stroke outcomes: a registry-based, prospective cohort study of acute stroke care in Surrey, UK. BMJ Open 2017; 7:e019122. [PMID: 29247109 PMCID: PMC5736041 DOI: 10.1136/bmjopen-2017-019122] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The relationship of anticoagulation therapies with stroke severity and outcomes have been well documented in the literature. However, none of the previous research has reported the relationship of atrial fibrillation (AF)/anticoagulation therapies with urinary tract infection (UTI), pneumonia and length of stay in hyperacute stroke units (HASUs). The present study aimed to evaluate AF and anticoagulation status in relation to early outcomes in 1387 men (median age=75 years, IQR=65-83) and 1371 women (median age=83 years, IQR=74-89) admitted with acute ischaemic stroke to HASUs in Surrey between 2014 and 2016. METHODS We conducted this registry-based, prospective cohort study using data from the Sentinel Stroke National Audit Programme. Association between AF anticoagulation status with severe stroke on arrival (National Institutes of Health Stroke Scale score ≥16), prolonged HASU stay (>3 weeks), UTI and pneumonia within 7 days of admission, severe disability on discharge (modified Rankin Scale score=4 and 5) and inpatient mortality was assessed by logistic regression, adjusted for age, sex, hypertension, congestive heart failure, diabetes and previous stroke. RESULTS Compared with patients with stroke who are free from AF, those with AF without anticoagulation had an increased adjusted risk of having more severe stroke: 5.8% versus 14.0%, OR=2.4 (95% CI 1.6 to 3.6, P<0.001), prolonged HASU stay: 21.5% versus 32.0%, OR=1.4 (1.0-2.0, P=0.027), pneumonia: 8.2% versus 19.1%, OR=2.1 (1.4-2.9, P<0.001), more severe disability: 24.2% versus 40.4%, OR=1.6 (1.2-2.1, P=0.004) and mortality: 9.3% versus 21.7%, OR=1.9 (1.4-2.8, P<0.001), and AF patients with anticoagulation also had greater risk for having UTI: 8.6% versus 12.3%, OR=1.9 (1.2-3.0, P=0.004), pneumonia: 8.2% versus 11.5%, OR=1.6 (1.1-2.4, P=0.025) and mortality: 9.7% versus 21.7%, OR=1.9 (1.4-2.8, P<0.001). The median HASU stay for stroke patients with AF without anticoagulation was 10.6 days (IQR=2.8-26.4) compared with 5.8 days (IQR=2.3-17.5) for those free from AF (P<0.001). CONCLUSIONS Patients with AF, particularly those without anticoagulation, are at increased risk of severe stroke, associated with prolonged HASU stay and increased risk of early infection, disability and mortality.
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Affiliation(s)
- Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
- Department of Endocrinology, Ashfordand St Peter's NHS Foundation Trust, Chertsey, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Brendan Affley
- Department of Stroke, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Giosue Gulli
- Department of Stroke, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | | | - Puneet Kakar
- Department of Stroke, Epsom and St Helier University Hospitals, Epsom, UK
| | - Tasmin Patel
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
| | - Sapna Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
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Frenkel MB, Renfrow JJ, Singh J, Garg N, Wolfe SQ. Combined interventional and surgical treatment of tandem middle cerebral artery embolus and internal carotid artery occlusion: case report. J Neurosurg 2017; 129:718-722. [PMID: 29148900 DOI: 10.3171/2017.6.jns162368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Tandem internal carotid artery (ICA) origin occlusion and middle cerebral artery (MCA) thromboembolism is a life-threatening condition with poor neurological outcome. The authors report on a patient presenting with acute ischemic stroke from a tandem ICA and MCA occlusion with penumbra. Emergency MCA mechanical thrombectomy was performed through percutaneous cervical ICA access due to the inability to cross the cervical carotid occlusion. Emergency carotid endarterectomy to reperfuse the poorly collateralized hemisphere and repair the ICA access site was performed 2 hours after completion of tissue plasminogen activator (tPA) infusion. This case illustrates the shortest reported interval between tPA infusion and open surgical intervention for carotid revascularization, as well as the role of direct carotid artery access for mechanical thrombectomy. The authors also describe the use of a temporizing femoral artery-to-ICA shunt to maintain cerebral perfusion in the setting of ICA occlusion.
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Affiliation(s)
| | | | | | - Nitin Garg
- 3Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Abstract
Significant advances in our understanding of transient ischemic attack (TIA) have taken place since it was first recognized as a major risk factor for stroke during the late 1950's. Recently, numerous studies have consistently shown that patients who have experienced a TIA constitute a heterogeneous population, with multiple causative factors as well as an average 5–10% risk of suffering a stroke during the 30 days that follow the index event. These two attributes have driven the most important changes in the management of TIA patients over the last decade, with particular attention paid to effective stroke risk stratification, efficient and comprehensive diagnostic assessment, and a sound therapeutic approach, destined to reduce the risk of subsequent ischemic stroke. This review is an outline of these changes, including a discussion of their advantages and disadvantages, and references to how new trends are likely to influence the future care of these patients.
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Affiliation(s)
- Camilo R Gomez
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Michael J Schneck
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Jose Biller
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
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Pérez Montilla M, Bravo Rey I, Bautista Rodríguez M, Alvarado S, Bravo-Rodríguez FA, Delgado Acosta F. Acute occlusion of a giant aneurysm of the internal carotid artery: Recanalisation of the middle cerebral artery through the contralateral carotid artery. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Mahmoud Fouad M, Mohamed Farag S, Hegazy MI, Abd Elalem Aziz M. Prediction of Functional Outcome in Ischemic Stroke Patients: An Observational Study on Egyptian Population. Cureus 2017; 9:e1392. [PMID: 28856071 PMCID: PMC5573338 DOI: 10.7759/cureus.1392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/25/2017] [Indexed: 11/21/2022] Open
Abstract
Introduction Determining the prognosis of ischemic stroke is important for neurologists and patients. The aim is to study the predictors of three months clinical outcome in ischemic stroke patients. Materials and methods A total of 397 patients were classified according to three months modified Rankin Scale score (mRS score) into two groups, favorable and unfavorable outcome. Favorable outcome was assumed if the score was zero or one, or unchanged if the score was ≥ 1 before the onset of the most recent event. Results The variables associated with unfavorable outcome were old age (P <0.001), presence of cardiac disease (P <0.001), low ejection fraction (P=0.008), low levels of total cholesterol and low-density lipoproteins (P <0.001), large artery atherosclerosis stroke (P <0.001), early confluent (P=0.005), high National Institute of Health stroke scale (NIHSS) score on admission (P <0.001), mRS score before admission (P <0.001), mRS score on discharge (P <0.001). Lacunar stroke was associated with favorable outcome (P <0.001). The regression analysis showed mRS score on discharge (P <0.001) and the presence of cardiac diseases (P=0.077) as independent predictors of unfavorable outcome. Conclusion High mRS score on discharge and presence of the cardiac disease independently could predict the unfavorable outcome and mRS score on discharge had a high sensitivity and negative predictive value in predicting the unfavorable outcome. Abbreviations MRS: score modified Rankin scale score, NIHSS: National Institutes of Health Stroke Scale, MRI: Magnetic resonance imaging, LDL: Low-density lipoprotein, MRA: Magnetic resonance of arteries.
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Christophe BR, Mehta SH, Garton ALA, Sisti J, Connolly ES. Current and future perspectives on the treatment of cerebral ischemia. Expert Opin Pharmacother 2017; 18:573-580. [PMID: 28393614 DOI: 10.1080/14656566.2017.1309022] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION After heart disease and combined forms of cancer, stroke is the leading cause of death in the United States. Currently, tissue-plasminogen activator (tPA) thrombolysis is the only thrombolytic therapy that has been shown to improve patient outcome. Presently, the only antithrombotic drug treatment that has proven effective at improving acute ischemic stroke patient outcome is aspirin administration. Despite these studies, no clinical trials have yet demonstrated a reliably effective pharmacological treatment. Areas covered: We conducted a search of recent drug studies for ischemic stroke on clinicaltrials.gov in addition to a literature search for acute ischemic stroke therapy using PubMed. This review details our findings of recent advancements in the pharmacological treatment of acute ischemic stroke. Expert commentary: We concluded that recent attempts to establish new pharmacological treatment protocols for acute ischemic stroke have had limited success, but many Phase III and Phase IV clinical trials demonstrate promise. Moreover, several studies have demonstrated the efficacy of dual-antiplatelet therapies at reducing risk of secondary stroke. Studies for novel therapeutic targets for neuroprotection have been largely unsuccessful. Some trials had positive results; however, there is much room for improvement and other studies show promise in their preliminary stages.
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Affiliation(s)
- Brandon R Christophe
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
| | - Shyle H Mehta
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
| | - Andrew L A Garton
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
| | - Jonathan Sisti
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
| | - E Sander Connolly
- a Department of Neurological Surgery , Columbia University Medical Center , New York , NY , USA
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Liberman AL, Zandieh A, Loomis C, Raser-Schramm JM, Wilson CA, Torres J, Ishida K, Pawar S, Davis R, Mullen MT, Messé SR, Kasner SE, Cucchiara BL. Symptomatic Carotid Occlusion Is Frequently Associated With Microembolization. Stroke 2017; 48:394-399. [PMID: 28077455 PMCID: PMC5821136 DOI: 10.1161/strokeaha.116.015375] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/17/2016] [Accepted: 11/30/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Symptomatic carotid artery disease is associated with significant morbidity and mortality. The pathophysiologic mechanisms of cerebral ischemia among patients with carotid occlusion remain underexplored. METHODS We conducted a prospective observational cohort study of patients hospitalized within 7 days of ischemic stroke or transient ischemic attack because of ≥50% carotid artery stenosis or occlusion. Transcranial Doppler emboli detection was performed in the middle cerebral artery ipsilateral to the symptomatic carotid. We describe the prevalence of microembolic signals (MES), characterize infarct topography, and report clinical outcomes at 90 days. RESULTS Forty-seven patients, 19 with carotid occlusion and 28 with carotid stenosis, had complete transcranial Doppler recordings and were included in the final analysis. MES were present in 38%. There was no difference in MES between those with carotid occlusion (7/19, 37%) compared with stenosis (11/28, 39%; P=0.87). In patients with radiographic evidence of infarction (n=39), 38% had a watershed pattern of infarction, 41% had a nonwatershed pattern, and 21% had a combination. MES were present in 40% of patients with a watershed pattern of infarction. Recurrent cerebral ischemia occurred in 9 patients (19%; 6 with transient ischemic attack, 3 with ischemic stroke). There was no difference in the rate of recurrence in those with compared to those without MES. CONCLUSIONS Cerebral embolization plays an important role in the pathophysiology of ischemia in both carotid occlusion and stenosis, even among patients with watershed infarcts. The role of aggressive antithrombotic and antiplatelet therapy for symptomatic carotid occlusions may warrant further investigation given our findings.
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Affiliation(s)
- Ava L Liberman
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.).
| | - Ali Zandieh
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Caitlin Loomis
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Jonathan M Raser-Schramm
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Christina A Wilson
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Jose Torres
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Koto Ishida
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Swaroop Pawar
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Rebecca Davis
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Michael T Mullen
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Steven R Messé
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Scott E Kasner
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
| | - Brett L Cucchiara
- From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.); Department of Neurology, University of Illinois, Chicago (A.Z.); Department of Neurology, Yale Medical School, New Haven, CT (C.L.); Department of Neurology, Christiana Care Health System, Wilmington, DE (J.M.R.-S.); Department of Neurology, University of Florida, Gainesville (C.A.W.); Department of Neurology, New York University Langone Medical Center (J.T., K.I.); Department of Neurology, Abington Memorial Hospital, PA (S.P.); Department of Internal Medicine (R.D.), Department of Neurology (M.T.M., S.R.M., S.E.K., B.L.C.), and Leonard Davis Institute, University of Pennsylvania, Philadelphia (M.T.M.)
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Murai R, Funakoshi S, Kaji S, Kitai T, Kim K, Koyama T, Furukawa Y. Outcomes of early surgery for infective endocarditis with moderate cerebral complications. J Thorac Cardiovasc Surg 2016; 153:831-840.e8. [PMID: 27988028 DOI: 10.1016/j.jtcvs.2016.10.074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 10/16/2016] [Accepted: 10/25/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We sought to clarify the effect of stroke severity on clinical outcomes in patients with infective endocarditis (IE) with cerebral complications and evaluate the impact of early surgery in the active phase on long-term prognosis in patients with nonsevere neurologic deficits. METHODS Clinical data were reviewed retrospectively in 170 consecutive patients with active left-sided IE with cerebral complications from 1990 to 2014. The mean age was 60 ± 17 years, and 93 (55%) were men. The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the severity of stroke. Major adverse cardiac events were defined as a composite of IE-related death, repeat surgery, and recurrence of IE. RESULTS Baseline NIHSS score was associated strongly with clinical outcome. When patients were divided into 2 groups according to NIHSS, 33 patients had severe stroke (NIHSS ≥11) and 137 had nonsevere stroke (NIHSS ≤10); freedom from IE-related death and major adverse cardiac events was significantly lower in patients with severe stroke than in those with nonsevere stroke. Of 137 patients with nonsevere stroke, 65 underwent early surgery within 2 weeks of onset, and conventional treatment was applied in 72. Freedom from IE-related death was significantly greater in patients undergoing early surgery than in those on conventional treatment (P = .007). Moreover, adjusted survival analysis using the inverse probability treatment weighting method showed a significant beneficial effect of early surgery in reducing IE-related death (P = .012) in patients with nonsevere stroke. CONCLUSIONS Early surgery might be beneficial in patients with nonsevere stroke.
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Affiliation(s)
- Ryosuke Murai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shunsuke Funakoshi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
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Choi JH, Park HS. Emergent Double-barrel Bypass Shortly after Intravenous Administration of Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke. J Cerebrovasc Endovasc Neurosurg 2016; 18:258-263. [PMID: 27847771 PMCID: PMC5104852 DOI: 10.7461/jcen.2016.18.3.258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/14/2016] [Accepted: 09/15/2016] [Indexed: 11/23/2022] Open
Abstract
Although intravenous recombinant tissue plasminogen activator (IV rt-PA) is effective in many cases of acute ischemic stroke, the neurologic symptoms can worsen after IV rt-PA because of sustained vessel occlusion. For such cases, several reperfusion modalities are available, including intra-arterial thrombolysis (IAT), carotid endarterectomy, and superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Invasive procedures, such as major surgery, should be generally avoided within 24 hours after the administration of IV rt-PA. A 66-year-old man with no previous medical history developed left hemiparesis. A computed tomography scan revealed no acute lesion and he received IV rt-PA within 1.5 hours after symptom onset. Emergent magnetic resonance imaging showed significant diffusion-perfusion mismatch. He received IAT 2 hours after IV rt-PA administration, but IAT failed because of total occlusion of the cervical internal carotid artery. We initially planned to perform STA-MCA bypass the next morning because he had received IV rt-PA, but, 8 hours after IV rt-PA administration, his hemiparesis worsened from motor grade 3/4 to motor grade 1/2. Because of the large perfusion defect in both MCA divisions, double-barrel STA-MCA bypass was performed 10 hours after IV rt-PA administration. His symptoms rapidly improved after surgery and his modified Rankin Scale score 3 months later was grade 0. We suggest that emergent double-barrel bypass can be a viable option in patients who have perfusion defects of both MCA divisions in acute ischemic stroke after IV rt-PA administration.
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Affiliation(s)
- Joon-Ho Choi
- Department of Neurosurgery, Busan-Ulsan Regional Cardio-Cerebrovascular Center, Medical Science Research Center, College of Medicine, Dong-A University, Busan, Korea
| | - Hyun-Seok Park
- Department of Neurosurgery, Busan-Ulsan Regional Cardio-Cerebrovascular Center, Medical Science Research Center, College of Medicine, Dong-A University, Busan, Korea
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Cohen JE, Leker RR, Eichel R, Gomori M, Itshayek E. Emergency endovascular revascularization of tandem occlusions: Internal carotid artery dissection and intracranial large artery embolism. J Clin Neurosci 2016; 28:157-61. [DOI: 10.1016/j.jocn.2015.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 12/05/2015] [Indexed: 11/28/2022]
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Pérez Montilla ME, Bravo Rey IM, Bautista Rodríguez MD, Alvarado SV, Bravo-Rodríguez FDA, Delgado Acosta F. Acute occlusion of a giant aneurysm of the internal carotid artery: Recanalisation of the middle cerebral artery through the contralateral carotid artery. Neurologia 2016; 32:480-484. [PMID: 26774414 DOI: 10.1016/j.nrl.2015.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/18/2015] [Accepted: 11/29/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- M E Pérez Montilla
- Sección de Neurorradiología Diagnóstica y Terapéutica, Unidad de Gestión Clínica de Radiodiagnóstico, Hospital Universitario Reina Sofía, Córdoba, España.
| | - I M Bravo Rey
- Sección de Neurorradiología Diagnóstica y Terapéutica, Unidad de Gestión Clínica de Radiodiagnóstico, Hospital Universitario Reina Sofía, Córdoba, España
| | | | - S V Alvarado
- Servicio de Neurología, Hospital Universitario Reina Sofía, Córdoba, España
| | - F de A Bravo-Rodríguez
- Sección de Neurorradiología Diagnóstica y Terapéutica, Unidad de Gestión Clínica de Radiodiagnóstico, Hospital Universitario Reina Sofía, Córdoba, España
| | - F Delgado Acosta
- Sección de Neurorradiología Diagnóstica y Terapéutica, Unidad de Gestión Clínica de Radiodiagnóstico, Hospital Universitario Reina Sofía, Córdoba, España
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Adams HP, Davis PH. Antithrombotic Therapy for Treatment of Acute Ischemic Stroke. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Yi X, Chi W, Wang C, Zhang B, Lin J. Low-molecular-weight heparin or dual antiplatelet therapy is more effective than aspirin alone in preventing early neurological deterioration and improving the 6-month outcome in ischemic stroke patients. J Clin Neurol 2015; 11:57-65. [PMID: 25628738 PMCID: PMC4302180 DOI: 10.3988/jcn.2015.11.1.57] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/28/2014] [Accepted: 09/29/2014] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Dual antiplatelet therapy (DAT) with clopidogrel and aspirin has been shown to confer greater protection against early neurological deterioration (END) and early recurrent ischemic stroke (ERIS) than aspirin alone in patients who have experienced an acute ischemic stroke. However, few studies have compared the effects of anticoagulation therapy with low-molecular-weight heparin (LMWH), DAT, and aspirin. METHODS Patients with acute ischemic stroke (n=1,467) were randomized to therapy groups receiving aspirin (200 mg daily for 14 days, followed by 100 mg daily for 6 months), DAT (200 mg of aspirin and 75 mg of clopidogrel daily for 14 days, then 100 mg of aspirin daily for 6 months), or LMWH (4,000 antifactor Xa IU of enoxaparin in 0.4 mL subcutaneously twice daily for 14 days, followed by 100 mg of aspirin daily for 6 months). The effects of these treatment strategies on the incidence of END, ERIS, and deep-vein thrombosis (DVT) were observed for 10-14 days after treatment, and their impacts on a good outcome were evaluated at 6 months. RESULTS The DAT and LMWH were associated with a more significant reduction of END and ERIS within 14 days compared with aspirin-alone therapy. In addition, LMWH was associated with a significantly lower incidence of DVT within 14 days. At 6 months, DAT or LMWH improved the outcome among patients aged >70 years and those with symptomatic stenosis in the posterior circulation or basilar artery compared with aspirin. CONCLUSIONS LMWH or DAT may be more effective than aspirin alone for reducing the incidence of END and ERIS within 14 days, and is associated with improved outcomes in elderly patients and those with stenosis in the posterior circulation or basilar artery at 6 months poststroke.
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Affiliation(s)
- Xingyang Yi
- Department of Neurology, People's Hospital of Deyang City, Deyang, China
| | - Wanzhang Chi
- Department of Neurology, Third Affiliated Hospital of Wenzhou Medical College, Wenzhou, China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang City, Deyang, China
| | - Biao Zhang
- Department of Neurology, People's Hospital of Deyang City, Deyang, China
| | - Jing Lin
- Department of Neurology, Third Affiliated Hospital of Wenzhou Medical College, Wenzhou, China
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Lescher S, Czeppan K, Porto L, Singer OC, Berkefeld J. Acute Stroke and Obstruction of the Extracranial Carotid Artery Combined with Intracranial Tandem Occlusion: Results of Interventional Revascularization. Cardiovasc Intervent Radiol 2014; 38:304-13. [DOI: 10.1007/s00270-014-1047-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/11/2014] [Indexed: 11/29/2022]
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Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, Dorn F. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 2014; 57:589-98. [PMID: 25404414 DOI: 10.1007/s00234-014-1465-5] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/04/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Acute tandem occlusions of the cervical and distal internal carotid artery (ICA) or middle cerebral artery (MCA) are associated with major stroke with intravenous (i.v.) thrombolysis alone in approximately 90 % of patients. The data on endovascular management of tandem occlusions is still limited. The purpose of this study was to review technical aspects and the current state of the literature on acute ICA stenting in combination with stent retriever-based intracranial thrombectomy. METHODS We retrospectively reviewed the data of 37 consecutive patients with tandem occlusions including clinical parameters, angiographic results, procedural aspects, complications, and hemorrhages. RESULTS Median National Institutes of Health Stroke Scale (NIHSS) on admission was 17 (3-30). Intracranial thrombectomy was performed prior to ICA stenting in 25/37 (67.6 %) and after stenting in 12/37 (32.4 %) patients. ICA stenting was successful in all cases, and a thrombolysis in cerebral infarction (TICI) scale 2b/3 result was achieved in 27/37 (73 %) cases. The mean angiography time was significantly shorter in the "thrombectomy first" group (43.1 ± 30.8 vs. 110.8 ± 43.0 min, p < 0.001), and more patients had favorable outcomes after 3 months (13/25 = 52.0 vs. 4/12 = 33.3 %, p = 0.319). In this group, intermediate catheters were used and successfully prevented embolism to unaffected territories in all cases. CONCLUSION Acute stenting of the cervical ICA in combination with intracranial thrombectomy was technically feasible and safe in our series. Thrombectomy prior to proximal stenting was associated with shorter reperfusion times and a tendency towards better clinical outcome leading to a good outcome in about 50 % of the patients. Therefore, we recommend this approach in tandem occlusion requiring stent angioplasty.
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Affiliation(s)
- H Lockau
- Department of Radiology, University Hospital of Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
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Lövkvist H, Jönsson AC, Luthman H, Jood K, Jern C, Wieloch T, Lindgren A. Variations in apolipoprotein D and sigma non-opioid intracellular receptor 1 genes with relation to risk, severity and outcome of ischemic stroke. BMC Neurol 2014; 14:191. [PMID: 25261976 PMCID: PMC4186220 DOI: 10.1186/s12883-014-0191-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 09/23/2014] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND In experimental studies, the apolipoprotein D (APOD) and the sigma receptor type 1 (SIGMAR1) have been related to processes of brain damage, repair and plasticity. METHODS We examined blood samples from 3081 ischemic stroke (IS) patients and 1595 control subjects regarding 10 single nucleotide polymorphisms (SNPs) in the APOD (chromosomal location 3q29) and SIGMAR1 (chromosomal location 9p13) genes to find possible associations with IS risk, IS severity (NIHSS-score) and recovery after IS (modified Rankin Scale, mRS, at 90 days). Simple/multiple logistic regression and Spearman's rho were utilized for the analyses. RESULTS Among the SNPs analyzed, rs7659 within the APOD gene showed a possible association with stroke risk (OR = 1.12; 95% CI: 1.01-1.25; P = 0.029) and stroke severity (NIHSS ≥ 16) (OR = 0.70; 95% CI: 0.54-0.92; P = 0.009) when controlling for age, sex and vascular risk factors for stroke. No SNP showed an association with stroke recovery (mRS). CONCLUSIONS We conclude that the SNP rs7659 within the APOD gene might be related to risk and severity of ischemic stroke in patients.
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Affiliation(s)
- Håkan Lövkvist
- />Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- />Department of Neurology and Rehabilitation Medicine, Neurology, Skåne University Hospital, Lund, Sweden
- />R&D Centre Skåne, Skåne University Hospital, SE-221 85 Lund, Sweden
| | | | - Holger Luthman
- />Department of Clinical Sciences Malmö, Medical Genetics, Lund University, Malmö, Sweden
| | - Katarina Jood
- />Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy at University of Gothenburg, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Christina Jern
- />Department of Clinical Neuroscience and Rehabilitation, The Sahlgrenska Academy at University of Gothenburg, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Tadeusz Wieloch
- />Department of Neurosurgery, Laboratory for Experimental Brain Research, Lund University, Lund, Sweden
| | - Arne Lindgren
- />Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- />Department of Neurology and Rehabilitation Medicine, Neurology, Skåne University Hospital, Lund, Sweden
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Lyden P, Levy H, Weymer S, Pryor K, Kramer W, Griffin JH, Davis TP, Zlokovic B. Phase 1 safety, tolerability and pharmacokinetics of 3K3A-APC in healthy adult volunteers. Curr Pharm Des 2014; 19:7479-85. [PMID: 24372304 DOI: 10.2174/1381612819666131230131454] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 11/19/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND PURPOSE Activated Protein C (APC) stimulates multiple cytoprotective pathways via the protease activated receptor-1 (PAR-1) and promotes anticoagulation. 3K3A-APC was designed for preserved activity at PAR-1 with reduced anticoagulation. This Phase 1 trial characterized pharmacokinetics and anticoagulation effects of 3K3A-APC. METHODS Subjects (n=64) were randomly assigned to receive 3K3A-APC (n=4) at 6, 30, 90, 180, 360, 540 or 720 µg/kg or placebo (n=6) and were observed for 24 hr. After safety review additional subjects received drug every 12 hr for 5 doses (n=6 per group) at 90, 180, 360, or 540 µg/kg or placebo (n=8) and were observed for 24 hr. RESULTS All subjects returned for safety assessments at 72 hours and 15 days. We found few adverse events in all groups. Systolic blood pressure increased in both active and placebo groups. Moderately severe headache, nausea and vomiting were reported in one of two subjects treated with 720 µg/kg so 540 µg/kg was considered the highest tolerated dose. Mean plasma concentrations increased in proportion to dose. Clearance ranged from 11,693 ± 807 to 18,701 ± 4,797 mL/hr, volume of distribution ranged from 4,873±828 to 6,971 ± 1,169 mL, and elimination half-life ranged from 0.211 ± 0.097 to 0.294 ± 0.054 hours. Elevations in aPTT were minimal. CONCLUSIONS 3K3A-APC was well tolerated at multiple doses as high as 540 µg/kg. These results should be confirmed in stroke patients with relevant co-morbidities. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01660230.
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Hong JH, Kang J, Jang MU, Kim BJ, Han MK, Park TH, Park SS, Lee KB, Lee BC, Yu KH, Oh MS, Cha JK, Kim DH, Lee J, Lee SJ, Ko Y, Park JM, Kang K, Cho YJ, Hong KS, Cho KH, Kim JT, Lee J, Lee JS, Bae HJ. Recanalization therapy for internal carotid artery occlusion presenting as acute ischemic stroke. J Stroke Cerebrovasc Dis 2014; 23:2183-2189. [PMID: 25018113 DOI: 10.1016/j.jstrokecerebrovasdis.2014.04.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/06/2014] [Accepted: 04/14/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND We aimed to describe the current status and clinical outcomes of recanalization therapy for internal carotid artery occlusion (ICAO) presenting as acute ischemic stroke. METHODS Using a nationwide stroke registry database in Korea, we identified consecutive ischemic stroke patients with ICAO hospitalized within 12 hours of onset between March 2010 and November 2011. RESULTS ICAO accounted for 10.6% (322 of 3028) of acute ischemic strokes within 12 hours of onset. Among the 322 ICAO patients, 53% underwent recanalization therapy, 41% intravenous thrombolysis (IVT) alone, and 59% endovascular treatment (EVT). Twenty-two percent of those with mild deficits (National Institutes of Health Stroke Scale <4) and 50% of those 80 years of age or more received recanalization therapy. Compared with no treatment, recanalization therapy was not significantly associated with a favorable outcome (3-month modified Rankin scale, 0-2) (adjusted odds ratio [OR], 1.77; 95% confidence interval [CI], .80-3.91; P = .16). However, compared with IVT, EVT significantly improved the odds of favorable outcome (OR, 2.86; 95% CI, 1.19-6.88; P = .02) without significant increase of symptomatic intracranial hemorrhage (OR, 2.18; 95% CI, .42-11.43; P = .36) and 3-month mortality (OR, .53; 95% CI, .23-1.18; P = .12). Successful recanalization rate (Thrombolysis in Cerebral Infarction ≥2a) by EVT was 76%. CONCLUSIONS In Korea, one tenth of acute ischemic stroke was caused by ICAO, and about 50% were treated by recanalization therapy. EVT was widely used as a recanalization modality (about 60% of cases) despite lack of evidence. However, its effectiveness and safety were acceptable.
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Affiliation(s)
- Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jihoon Kang
- Department of Neurology, Sungkyunkwan University Samsung Changwon Hospital School of Medicine, Changwon, Korea
| | - Min Uk Jang
- Department of Neurology, Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Asan, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Jae Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University School of Medicine, Daegu, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University College of Medicine, Daejeon, Korea
| | - Youngchai Ko
- Department of Neurology, Eulji University Hospital, Eulji University College of Medicine, Daejeon, Korea
| | - Jong-Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Kyusik Kang
- Department of Neurology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Medical School, Gwangju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Biostatistical Consulting Unit, Soonchunhyang University Medical Center of Biostatistics, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea.
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Low-molecular-weight heparin is more effective than aspirin in preventing early neurologic deterioration and improving six-month outcome. J Stroke Cerebrovasc Dis 2014; 23:1537-44. [PMID: 24656240 DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 12/17/2013] [Accepted: 12/20/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND We evaluated the efficacy of low-molecular-weight heparin (LMWH) relative to aspirin in preventing early neurologic deterioration (END), venous thromboembolism (VTE), and outcomes at 6 months. METHODS Patients were randomly assigned to receive either subcutaneous enoxaparin 4000 anti-factor Xa IU/0.4 mL twice daily or oral aspirin 200 mg daily for 10 days. After day 10, all subjects received aspirin 100 mg once daily for 6 months. We assessed whether LMWH was superior to aspirin in preventing END and VTE within the first 10 days after index stroke and evaluated 6-month outcomes. FINDINGS Of the total 1368 patients, 7.89% suffered from END, and 2.85% suffered from deep-vein thrombosis during the first 10 days, with a significance difference between the LMWH group and aspirin group (3.95%, 1.46% versus 11.82%, 4.23%, respectively). At 6 months, there was a significant difference in the frequency of good outcomes among patients over the median age of 70 years (LMWH 63.8% versus aspirin 44.6%). The benefit of LMWH was also significant in patients with symptomatic stenosis of the posterior circulation and basilar artery (75.2% and 82% for LMWH versus 40.5% and 48% for aspirin, respectively). CONCLUSIONS For patients with acute ischemic stroke, treatment with LMWH within 48 hours of stroke until 10 days later may reduce END and deep-vein thrombosis during the first 10 days. LMWH appears to have advantages over aspirin in certain subgroups, such as elderly patients and patients with posterior circulation and basilar artery stenosis.
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Choi JY, Lee JI, Lee TH, Sung SM, Cho HJ, Ko JK. Emergent Recanalization with Stenting for Acute Stroke due to Athero-Thrombotic Occlusion of the Cervical Internal Carotid Artery : A Single Center Experience. J Korean Neurosurg Soc 2014; 55:313-20. [PMID: 25237426 PMCID: PMC4166326 DOI: 10.3340/jkns.2014.55.6.313] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/26/2014] [Accepted: 06/11/2014] [Indexed: 12/02/2022] Open
Abstract
Objective The purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent carotid angioplasty and stenting (CAS) for acute stroke due to athero-thrombotic occlusion of the cervical internal carotid artery (ICA). Methods Review of medical records identified 17 patients who underwent emergent CAS for treatment of athero-thrombotic occlusion of the cervical ICA with acute stroke between 2009 and 2013. Eleven patients (64.7%) presented with concomitant intracranial artery occlusion, which was treated primarily by mechanical thrombectomy after CAS. Results Successful revascularization of the cervical ICA with emergent CAS was achieved in all patients. After CAS, intracranial recanalization with Thrombolysis in Cerebral Infarction ≥2b flow was achieved in four of the 11 patients (36.4%). The overall recanalization rate (cervical ICA and intracranial artery) was 10 of 17 patients (58.8%). Symptomatic intracranial hemorrhage occurred in two patients (11.8%), resulting in death. Ten patients (58.8%) showed improvement (decrease in NIHSS score of ≥4 points) at seven days after recanalization. Nine patients (52.9%) showed a favorable outcome (mRS ≤2) at the last follow-up. A favorable outcome (mRS ≤2) was obtained in four of the six patients with isolated cervical ICA occlusion (4/6, 66.7%) and five of 11 patients with intracranial tandem occlusion (5/11, 45.5%). Conclusion Emergent CAS for acute stroke due to athero-thrombotic occusion of the cervical ICA showed a good technical feasibility and favorable clinical outcome.
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Affiliation(s)
- Jae Young Choi
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Tae Hong Lee
- Department of Diagnostic Radiology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sang Min Sung
- Department of Neurology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Han Jin Cho
- Department of Neurology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jun Kyeung Ko
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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Cohen JE, Gomori JM, Rajz G, Itshayek E, Eichel R, Leker RR. Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandem occlusive disease. J Neurointerv Surg 2014; 7:412-7. [PMID: 24727131 DOI: 10.1136/neurintsurg-2014-011175] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/27/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Acute tandem occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. We describe our experience with emergency stent-assisted ICA angioplasty and intracranial stent-based thrombectomy of tandem occlusions. METHODS Procedures were performed from March 2010 to December 2013. National Institutes of Health Stroke Score (NIHSS) and Alberta Stroke Program Early CT Score (ASPECTS), occlusion sites, collateral supply, procedural details, and outcomes were retrospectively reviewed with IRB waiver of informed consent. RESULTS 24 patients, mean age 66 years, mean admission NIHSS 20.4, and mean ASPECTS 9 were included. Occlusion sites were proximal ICA-middle cerebral artery (MCA) trunk in 17 patients, proximal ICA-ICA terminus in six, and ICA-MCA-anterior cerebral artery in one. Stent-assisted cervical ICA recanalization was achieved in all patients, with unprotected pre-angioplasty in 24/24, unprotected stenting in 16/24 (67%), and protected stenting in 8/24 (33%), followed by stent-thrombectomy in 25 intracranial occlusions. There was complete recanalization/complete perfusion in 19/24 (79%), complete recanalization/partial perfusion in 3/24 (13%), and partial recanalization/partial perfusion in 2/24 (8%) with no procedural morbidity/mortality. Mean time to therapy was 3.8 h (range 2-5.5) and mean time to recanalization was 51 min (range 38-69). At 3-month follow-up, among 17/22 surviving patients (77%), 13/17 (76%) were modified Rankin Scale (mRS) 0-2 and 3/17 (18%) were mRS 3. CONCLUSIONS In acute tandem ICA-MCA/distal ICA occlusions, extracranial stenting followed by intracranial stent-based thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.
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Affiliation(s)
- José E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J Moshe Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Gustavo Rajz
- Department of Neurosurgery, Sheba Medical Center, Tel Aviv, Israel
| | - Eyal Itshayek
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Roni Eichel
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Predictive ability of C-reactive protein for early mortality after ischemic stroke: comparison with NIHSS score. Acta Neurol Belg 2014; 114:41-5. [PMID: 23975559 DOI: 10.1007/s13760-013-0238-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/23/2013] [Indexed: 01/22/2023]
Abstract
We aimed to compare the association of high-sensitivity C-reactive protein (CRP) and National Institutes of Health Stroke Scale (NIHSS) score with mortality risk and to determine the optimal threshold of CRP for prediction of mortality in ischemic-stroke patients. A series of 162 patients with first-ever ischemic-stroke admitted within 24 h after onset of symptoms was enrolled. CRP and NIHSS score were estimated on admission and their predictive abilities for mortality at 7 days were determined by logistic-regression analyses. Receiver-Operating Characteristic (ROC) curves were depicted to identify the optimal cut-off of CRP, using the maximum Youden-index and the shortest-distance methods. Deceased patients had higher levels of CRP and NIHSS on admission (8.87 ± 7.11 vs. 2.20 ± 4.71 mg/l for CRP, and 17.31 ± 6.36 vs. 8.70 ± 4.85 U for NIHSS, respectively, P < 0.01). CRP and NIHSS were correlated with each other (r (2) = 0.39, P < 0.001) and were also independently associated with increased risk of mortality [odds ratios (95 % confidence interval) of 1.16 (1.05-1.28) and 1.20 (1.07-1.35) for CRP and NIHSS, respectively, P < 0.01]. The areas under the ROC curves of CRP and NIHSS for mortality were 0.82 and 0.84, respectively. The CRP value of 2.2 mg/l was identified as the optimal cut-off value for prediction of mortality within 7 days (sensitivity: 0.81, specificity: 0.80). Thus, CRP as an independent predictor of mortality following ischemic-stroke is comparable with NIHSS and the value of 2.2 mg/l yields the optimum sensitivity and specificity for mortality prediction.
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42
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Eikelboom JW, Hart RG. Anticoagulant therapy in acute brain ischaemia. Lancet Neurol 2013; 12:526-7. [DOI: 10.1016/s1474-4422(13)70083-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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43
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Abstract
As stroke care has developed, there has been a need to robustly assess the efficacy of interventions both at the level of the individual stroke survivor and in the context of clinical trials. To describe stroke-survivor recovery meaningfully, more sophisticated measures are required than simple dichotomous end points, such as mortality or stroke recurrence. As stroke is an exemplar disabling long-term condition, measures of function are well suited as outcome assessment. In this review, we will describe functional assessment scales in stroke, concentrating on three of the more commonly used tools: the National Institutes of Health Stroke Scale, the modified Rankin Scale, and the Barthel Index. We will discuss the strengths, limitations, and application of these scales and use the scales to highlight important properties that are relevant to all assessment tools. We will frame much of this discussion in the context of "clinimetric" analysis. As they are increasingly used to inform stroke-survivor assessments, we will also discuss some of the commonly used quality-of-life measures. A recurring theme when considering functional assessment is that no tool suits all situations. Clinicians and researchers should chose their assessment tool based on the question of interest and the evidence base around clinimetric properties.
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Affiliation(s)
- Jennifer K Harrison
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Katherine S McArthur
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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44
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Abstract
Acute ischemic stroke (AIS) is the fourth leading cause of death and the leading cause of adult disability in the USA. AIS most commonly occurs when a blood vessel is obstructed leading to irreversible brain injury and subsequent focal neurologic deficits. Drug treatment of AIS involves intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator [rtPA]). Intravenous alteplase promotes thrombolysis by hydrolyzing plasminogen to form the proteolytic enzyme plasmin. Plasmin targets the blood clot with limited systemic thrombolytic effects. Alteplase must be administered within a short time window to appropriate patients to optimize its therapeutic efficacy. Recent trials have shown this time window may be extended from 3 to 4.5 hours in select patients. Other acute supportive interventions for AIS include maintaining normoglycemia, euthermia and treating severe hypertension. Urgent anticoagulation for AIS has generally not shown benefits that exceed the hemorrhage risks in the acute setting. Urgent antiplatelet use for AIS has limited benefits and should only promptly be initiated if alteplase was not administered, or after 24 hours if alteplase was administered. The majority of AIS patients do not receive thrombolytic therapy due to late arrival to emergency departments and currently there is a paucity of acute interventions for them. Ongoing clinical trials may lead to further medical breakthroughs to limit the damage inflicted by this devastating disease.
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Affiliation(s)
- Sameer Bansal
- Department of Neurology, University of Cincinnati, College of Medicine, Cincinnati, OH 45267, USA
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45
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3207] [Impact Index Per Article: 291.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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46
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Mpotsaris A, Bussmeyer M, Buchner H, Weber W. Clinical outcome of neurointerventional emergency treatment of extra- or intracranial tandem occlusions in acute major stroke: antegrade approach with wallstent and solitaire stent retriever. Clin Neuroradiol 2013; 23:207-15. [PMID: 23354342 DOI: 10.1007/s00062-013-0197-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 01/02/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute large cerebral artery occlusions respond poorly to systemic thrombolysis with recombinant tissue plasminogen activator (rTPA) alone. The value of stent retriever-based mechanical thrombectomy in patients with additional extracranial occlusion of the internal carotid artery (ICA), who require acute a priori extracranial stenting in order to reach the intracranial obstruction site, is not well known. We determined the outcome after emergency revascularization in acute stroke with tandem occlusions of the anterior circulation. METHODS According to specific inclusion/exclusion criteria, eligible stroke patients with large artery occlusions underwent mechanical recanalization with the Solitaire stent retriever. In case of a tandem occlusion, we performed an acute stenting with the Wallstent before thrombectomy. From October 2009 to March 2011, 50 patients were treated according to this protocol; time frames, clinical data, recanalization rates, and midterm outcome were recorded. RESULTS Forty-one patients had a large artery occlusion in the anterior circulation and nine in the posterior circulation. Mechanical recanalization was successful in 35/41 cases (85 %). Six of 41 patients (15 %) died in the acute phase. In 17/41 patients (42 %), thrombectomy was preceded by an emergency stenting in the extracranial portion of the internal carotid artery (ICA). National Institutes of Health Stroke Scale (NIHSS)/modified Rankin Scale (mRS) scores showed significant improvement in both the stenting group and the nonstenting group; there were no significant differences between the groups. At 90 days, 54 % of patients with emergency stenting had a good outcome. CONCLUSIONS Acute extracranial stenting with the Wallstent combined with intracranial Solitaire-based thrombectomy is safe and may lead to an improvement in neurological outcome in patients with an otherwise poor prognosis under i.v. thrombolysis alone.
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Affiliation(s)
- A Mpotsaris
- Klinik für Radiologie, Neuroradiologie und interventionelle Therapie, Klinikum Vest, Knappschaftskrankenhaus, Dorstener Str. 151, 45657, Recklinghausen, Germany.
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47
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Grubb RL, Powers WJ, Clarke WR, Videen TO, Adams HP, Derdeyn CP. Surgical results of the Carotid Occlusion Surgery Study. J Neurosurg 2013; 118:25-33. [PMID: 23101451 PMCID: PMC4246998 DOI: 10.3171/2012.9.jns12551] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The Carotid Occlusion Surgery Study (COSS) was conducted to determine if superficial temporal artery-middle cerebral artery (STA-MCA) bypass, when added to the best medical therapy, would reduce subsequent ipsilateral stroke in patients with complete internal carotid artery (ICA) occlusion and an elevated oxygen extraction fraction (OEF) in the cerebral hemisphere distal to the occlusion. A recent publication documented the methodology of the COSS in detail and briefly outlined the major findings of the trial. The surgical results of the COSS are described in detail in this report. METHODS The COSS was a prospective, parallel-group, 1:1 randomized, open-label, blinded-adjudication treatment trial. Participants, who had angiographically demonstrated complete occlusion of the ICA causing either a transient ischemic attack or ischemic stroke within 120 days and hemodynamic cerebral ischemia indicated by an increased OEF measured by PET, were randomized to either surgical or medical treatment. One hundred ninety-five patients were randomized: 97 to the surgical group and 98 to the medical group. The surgical patients underwent an STA-MCA cortical branch anastomosis. RESULTS In the intention-to-treat analysis, the 2-year rates for the primary end point were 21% for the surgical group and 22.7% for the medical group (p = 0.78, log-rank test). Fourteen (15%) of the 93 patients who had undergone an arterial bypass had a primary end point ipsilateral hemispheric stroke in the 30-day postoperative period, 12 within 2 days after surgery. The STA-MCA arterial bypass patency rate was 98% at the 30-day postoperative visit and 96% at the last follow-up examination. The STA-MCA arterial bypass markedly improved, although it did not normalize, the level of elevated OEF in the symptomatic cerebral hemisphere. Five surgically treated and 1 nonsurgically treated patients in the surgical group had a primary end point ipsilateral hemispheric stroke after the 30-day postoperative period. No baseline characteristics or intraoperative variables revealed those who would experience a procedure-related stroke. CONCLUSIONS Despite excellent bypass graft patency and improved cerebral hemodynamics, STA-MCA anastomosis did not provide an overall benefit regarding ipsilateral 2-year stroke recurrence, mainly because of a much better than expected stroke recurrence rate (22.7%) in the medical group, but also because of a significant postoperative stroke rate (15%). Clinical trial registration no.: NCT00029146.
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Affiliation(s)
- Robert L Grubb
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, Missouri 63110, USA.
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Telman G, Sprecher E, Kouperberg E. Carotid disease in acute ischemic stroke patients of northern Israel. Acta Neurol Scand 2012; 126:398-403. [PMID: 22435882 DOI: 10.1111/j.1600-0404.2012.01663.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carotid disease complicated by thrombosis or embolism is a frequent cause of acute ischemic stroke. The aim of the study was to determine factors associated with carotid disease in patients suffering from acute ischemic stroke in northern Israel. METHODS Participants were 1378 acute ischemic stroke patients, including 671 patients with and 707 patients without carotid plaques, as defined by cervical ultrasound. RESULTS Logistic regression analysis of possible predictors revealed that age, male gender, diabetes, hyperlipidemia, and smoking were independent predictors for the presence of carotid plaque. Male gender was independently associated with the increased prevalence of carotid stenosis of 50% or more, as well as with symptomatic carotid plaques. Age was found to be the only independent factor influencing the extent (bilateral vs unilateral) of carotid disease among acute ischemic stroke patients in northern Israel. Although ethnicity was initially found to have an influence on the prevalence of carotid plaques (higher among Jews than Arabs), no such influence was found after logistic regression. CONCLUSION Our findings emphasize that demographic characteristics (age, gender) and vascular risk factors (diabetes, smoking and hyperlipidemia) rather than ethnic disparities are important determinants of carotid disease in acute ischemic stroke patients in northern Israel.
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Affiliation(s)
- G. Telman
- Department of Neurology, Rambam Medical Center; Technion Faculty of Medicine; Haifa; Israel
| | - E. Sprecher
- Department of Neurology, Rambam Medical Center; Technion Faculty of Medicine; Haifa; Israel
| | - E. Kouperberg
- Department of Neurology, Rambam Medical Center; Technion Faculty of Medicine; Haifa; Israel
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49
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Kwak HS, Hwang SB, Jin GY, Hippe DS, Chung GH. Predictors of functional outcome after emergency carotid artery stenting and intra-arterial thrombolysis for treatment of acute stroke associated with obstruction of the proximal internal carotid artery and tandem downstream occlusion. AJNR Am J Neuroradiol 2012; 34:841-6. [PMID: 23139078 DOI: 10.3174/ajnr.a3304] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patients who develop severe stroke symptoms due to acute internal carotid artery occlusion eventually in combination with a thromboembolic obstruction of the middle cerebral artery incur a major risk of developing extensive MCA infarction with a poor outcome. The purpose of this study was to evaluate the outcome for patients with tandem occlusions in the MCA and/or distal ICA, retrospectively, who had undergone stent implantation in the proximal segment of the ICA in addition to intra-arterial thrombolysis. MATERIALS AND METHODS Thirty-five patients with tandem occlusions of the MCA and/or distal ICA and acute occlusion of the proximal ICA underwent stent implantation for the proximal ICA occlusion and IAT for the tandem occlusion. Clinical outcome measures were assessed on admission and at discharge by using the National Institutes of Health Stroke Scale as well as 3 months after treatment by using the modified Rankin Scale. RESULTS The median NIHSS score on admission was 12 (range, 6-22). All patients had patent flow into the M1 and ICA after carotid artery stent placement and IAT. After the procedure, 19 patients (54.3%) were TICI grade III; 7 (20.0%), TICI grade IIb; and 9 (25.7%), TICI grade IIa. Symptomatic intracerebral hemorrhage occurred in 1 patient (2.9%). The overall mortality rate was 11.4% (4/35). At 3-month follow-up, the median NIHSS score was 4 (range, 1-17). NIHSS score at admission and TICI grade were all found to be independently associated with an unfavorable outcome at 3 months. CONCLUSIONS Initial stroke severity, degree of successful revascularization, and the side of ischemia were found to independently predict the functional outcome at 3 months after treatment.
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Affiliation(s)
- H S Kwak
- Department of Radiology and Research Institute of Medical Science, Chonbuk National University Medical School and Hospital, Chonbuk, South Korea.
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50
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Li AH, Wang YH, Kao HF, Yang LH, Chan L, Chu SH, Liu HM. Aggressive revascularization of acute internal carotid artery occlusion in patients with NIHSS>20 and poor collateral circulation: Preliminary report. Int J Cardiol 2012; 161:97-102. [DOI: 10.1016/j.ijcard.2011.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 04/06/2011] [Accepted: 05/06/2011] [Indexed: 11/30/2022]
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