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Elfil M, Ghaith HS, Bayoumi A, Elmashad A, Aladawi M, Al-Ani M, Najdawi Z, Mammadli G, Russo B, Toth G, Nour M, Asif K, Nguyen TN, Gandhi CD, Kaur G, Hussain MS, Czap AL, El-Ghanem M, Mansour OY, Khandelwal P, Mayer S, Al-Mufti F. Impact of pre-treatment cerebral microbleeds on the outcomes of endovascular thrombectomy: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107324. [PMID: 37660553 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE/AIM To investigate the effect of cerebral microbleeds (CMBs) on the functional and safety outcomes of endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). METHODS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for systematic review and meta-analysis. We included observational studies that recruited AIS-LVO patients, used susceptibility-sensitive magnetic resonance imaging (MRI) to detect CMBs, and examined the association between them and predefined outcome events. The extracted data included study and population characteristics, risk of bias domains, and outcome measures. The outcomes of interest included functional independence, revascularization success, procedural and hemorrhagic adverse events. We conducted a meta-analysis using the Mantel-Haenszel method and calculated the risk ratios. RESULTS Four studies with a total of 1,514 patients were included. A significant reduction in the likelihood of achieving a favorable functional outcome was observed in patients with CMBs (Risk ratio (RR) 0.69, 95% confidence interval (CI): 0.52 to 0.91, P=0.01). No significant differences were observed between the CMBs and no CMBs groups in terms of successful revascularization, mortality, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and parenchymal hematoma. CONCLUSIONS The presence of CMBs significantly reduced the likelihood of achieving functional independence post-EVT in AIS-LVO patients. However, CMBs did not impact the rates of successful revascularization, mortality, or the occurrence of various hemorrhagic events. Future research should explore the mechanisms of this association and strategies to mitigate its impact.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ahmed Bayoumi
- Department of Neurology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Ahmed Elmashad
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mina Al-Ani
- Department of Radiology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Zaid Najdawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Gular Mammadli
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Brittany Russo
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kaiz Asif
- Ascension Health and University of Illinois-Chicago, Chicago, IL, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - M Shazam Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandra L Czap
- Department of Neurology, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Mohammad El-Ghanem
- Neuroendovascular Surgery, HCA Houston Northwest/University of Houston College of Medicine, Houston, TX, USA
| | - Ossama Yassin Mansour
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Stephan Mayer
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.
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Azzam AY, Ghozy S, Kallmes KM, Adusumilli G, Heit JJ, Hassan AE, Kadirvel R, Kallmes DF. Aspiration thrombectomy versus stent retriever thrombectomy alone for acute ischemic stroke: evaluating the overlapping meta-analyses. J Neurointerv Surg 2023; 15:34-38. [PMID: 35584912 PMCID: PMC9898825 DOI: 10.1136/neurintsurg-2022-018849] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Previous studies comparing a direct aspiration first pass technique (ADAPT) and stent retrievers have inconsistent methodologies and data reporting, limiting the ability to accurately assimilate data from different studies that would inform treatment of acute ischemic stroke (AIS) treatment. OBJECTIVE To conduct a systematic review to discuss and compare the findings of all relevant meta-analysis studies comparing the efficacy of the ADAPT and stent retriever techniques. METHODS The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), where meta-analyses comparing the efficacy of the ADAPT technique and stent retrievers in the treatment of AIS were included. We extracted all relevant data from the included studies and assessed the quality of the included meta-analyses using the Assessment of Multiple Systematic Review (AMSTAR-2). RESULTS Seven relevant studies met our inclusion criteria and were suitable for the qualitative synthesis. All included studies obtained data from randomized controlled trials (RCTs) and observational investigations (including levels II, III, and IV). At the same time, none of them used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) for quality assessment. In accordance with AMSTAR-2, two studies were rated 'high', while the other five were rated 'moderate'. CONCLUSIONS Present evidence is insufficient to clarify the superiority of one modality over the other. Further RCTs on this comparison must be conducted prior to designing further meta-analyses or making conclusive interpretations. Procedure duration and cost should be taken into consideration for any future studies.
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Affiliation(s)
- Ahmed Y Azzam
- October 6 University Faculty of Medicine, 6th of October City, Egypt
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | | | - Gautam Adusumilli
- Department of Radiology and Neurosurgery, Stanford University, Stanford, California, USA
| | - Jeremy J Heit
- Radiology, Neuroadiology, and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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Elfil M, Bahbah EI, Bayoumi A, Aladawi M, Eldokmak M, Salem MM, Aboutaleb PE, Villafuerte-Trisolini B, Al-Mufti F, Ortega-Gutierrez S, A Gonzalez-Castellon M. Repeated mechanical thrombectomy for recurrent large vessel occlusion: A systematic review and meta-analysis. Interv Neuroradiol 2022:15910199221134307. [PMID: 36285483 DOI: 10.1177/15910199221134307] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusion (LVO). Recurrent LVO can still occur in patients who already underwent MT for the first LVO. This study aimed to evaluate the efficacy of repeating MT for recurrent LVO. METHODS This meta-analysis of the available literature was conducted to summarize the current evidence regarding repeated MT outcomes in patients with recurrent LVO. All studies with ≥ 1 outcomes of interest were included. The Newcastle-Ottawa Scale (NOS) was used for risk of bias assessment. RESULTS Twenty studies, 10 observational (n = 21,251 patients) and 10 case reports (n = 10 patients), were included. 266 patients (62.78% females) with recurrent LVO were identified, with an overall prevalence of 1.6% and a mean age of 65.67 ± 16.23 years. Cardio-embolism was the most common mechanism in both times, with a median of 15 days between the first and second LVOs. Compared with pre-intervention, the first and second MTs significantly reduced the National Institute of Health Stroke Scale (NIHSS) score, (mean difference (MD) = -8.91) and (MD = -5.97) respectively, with a significant difference (p = 0.001). The rate of favorable outcome (modified Rankin scale (mRS) score 0-3) was 82.6% and 59.2% after the first and second MTs respectively, with a significant difference (p < 0.001). CONCLUSION In properly selected recurrent LVO patients, repeated MT is efficacious and safe. A prior MT procedure should not discourage aggressive treatment as many patients may achieve favorable outcomes.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Eshak I Bahbah
- 486471Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | - Ahmed Bayoumi
- 12339McGovern Medical School, UT Houston, Houston, TX, USA
| | - Mohammad Aladawi
- Department of Neurological Sciences, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Mohamed Eldokmak
- Department of Neurology, 12298SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the 6572University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Pakinam E Aboutaleb
- Department of Neurology, Hospital of the 6572University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | | | - Fawaz Al-Mufti
- Department of Neurosurgery, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
- Department of Neurology, 8138Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, 21782University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery, 21782University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Radiology, 21782University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Bücke P, Cohen JE, Horvath T, Cimpoca A, Bhogal P, Bäzner H, Henkes H. What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review. Rev Cardiovasc Med 2022; 23:340. [PMID: 39077121 PMCID: PMC11267361 DOI: 10.31083/j.rcm2310340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/08/2022] [Accepted: 06/08/2022] [Indexed: 07/31/2024] Open
Abstract
In 2015, mechanical thrombectomy (MT) in combination with intravenous thrombolysis was demonstrated to be superior to best medical treatment alone in patients with anterior circulation stroke. This finding resulted in an unprecedented boost in endovascular stroke therapy, and MT became widely available. MT was initially approved for patients presenting with large vessel occlusion in the anterior circulation (intracranial internal carotid artery or proximal middle cerebral artery) within a 6-hour time window. Eventually, it was shown to be beneficial in a broader group of patients, including those without known symptom-onset, wake-up stroke, or patients with posterior circulation stroke. Technical developments and the implementation of novel thrombectomy devices further facilitated endovascular recanalization for acute ischemic stroke. However, some aspects remain controversial. Is MT suitable for medium or very distal vessel occlusions? Should emergency stenting be performed for symptomatic stenosis or recurrent occlusion? How should patients with large vessel occlusion without disabling symptoms be treated? Do certain patients benefit from MT without intravenous thrombolysis? In the era of personalized decision-making, some of these questions require an individualized approach based on comorbidities, imaging criteria, and the severity or duration of symptoms. Despite its successful development in the past decade, endovascular stroke therapy will remain a challenging and fascinating field in the years to come. This review aims to provide an overview of patient selection, and the indications for and execution of MT in patients with acute ischemic stroke.
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Affiliation(s)
- Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Jose E. Cohen
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University Jerusalem, 91905 Jerusalem, Israel
| | - Thomas Horvath
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Alexandru Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Pervinder Bhogal
- Interventional Neuroradiology Department, The Royal London Hospital, E1 1FR London, UK
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
- Medical Faculty, Universität Duisburg-Essen, 45141 Essen, Germany
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Kwak Y, Son W, Kim BJ, Kim M, Yoon SY, Park J, Lim J, Kim J, Kang DH. Frictional force analysis of stent retriever devices using a realistic vascular model: Pilot study. Front Neurol 2022; 13:964354. [PMID: 36090887 PMCID: PMC9449119 DOI: 10.3389/fneur.2022.964354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To date, no vascular model to analyze frictional forces between stent retriever devices and vessel walls has been designed to be similar to the real human vasculature. We developed a novel in vitro intracranial cerebrovascular model and analyzed frictional forces of three stent retriever devices. Methods A vascular mold was created based on digital subtraction angiography of a patient's cerebral vessels. The vascular model was constructed using polydimethylsiloxane (PDMS, Dow Corning, Inc.) as a silicone elastomer. The vascular model was coated on its inner surface with a lubricating layer to create a low coefficient of friction (~0.037) to closely approximate the intima. A pulsatile blood pump was used to produce blood flow inside the model to approximate real vascular conditions. The frictional forces of Trevo XP, Solitaire 2, and Eric 4 were analyzed for initial and maximal friction retrieval forces using this vascular model. The total pulling energy generated during the 3 cm movement was also obtained. Results Results for initial retrieval force were as follows: Trevo, 0.09 ± 0.04 N; Solitaire, 0.25 ± 0.07 N; and Eric, 0.33 ± 0.21 N. Results for maximal retrieval force were as follows: Trevo, 0.36 ± 0.07 N; Solitaire, 0.54 ± 0.06 N; and Eric, 0.80 ± 0.13 N. Total pulling energy (N·cm) was 0.40 ± 0.10 in Trevo, 0.65 ± 0.10 in Solitaire, and 0.87 ± 0.14 in Eric, respectively. Conclusions Using a realistic vascular model, different stent retriever devices were shown to have statistically different frictional forces. Future studies using a realistic vascular model are warranted to assess SRT devices.
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Affiliation(s)
- Youngseok Kwak
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Wonsoo Son
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Byoung-Joon Kim
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Myungsoo Kim
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sang-Youl Yoon
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jaechan Park
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jongkyeong Lim
- Department of Mechanical Engineering, Gachon University, Seongnam-si, South Korea
| | - Joonwon Kim
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), Pohang, South Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea
- Departement of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea
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