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Takaishi S, Ueda T, Usuki N, Tatsuno K, Yoshie T, Yamano Y. Age-related differences in diffusion-weighted imaging lesion volume and reversal in patients with successful recanalization after mechanical thrombectomy. J Neurointerv Surg 2024:jnis-2024-021922. [PMID: 39137968 DOI: 10.1136/jnis-2024-021922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 07/30/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND With the advancement of mechanical thrombectomy (MT), post-treatment diffusion-weighted imaging (DWI) lesion reversal (DWIR) has been reported. This study aimed to compare the volumes of DWI lesions and the frequencies of DWIR between younger and elderly patients who underwent successful recanalization with MT. METHODS The study retrospectively analyzed 177 consecutive patients who underwent successful recanalization with MT for anterior large vessel occlusion (LVO) at our hospital between April 2011 and September 2022. Patients were categorized into two age groups: <70 years and ≥70 years. MRI was performed before treatment and 24 hours after treatment. The DWI lesion volumes and DWIR frequencies were compared between the two groups. RESULTS The median age of the patients was 78 years and 19.8% were in the <70 years group. No significant differences were found between the groups in terms of occluded vessel sites and recanalization time. The baseline DWI lesion was significantly larger in the <70 years group (16.0 mL vs 4.0 mL, P<0.001). The frequency of DWIR did not significantly differ between the groups (65.7% vs 55.6%). DWI lesion volume significantly decreased after treatment in the <70 years group but showed no significant change in the ≥70 years group. CONCLUSIONS In patients who underwent successful recanalization after MT for anterior LVO, baseline DWI lesions were significantly larger in younger patients compared with elderly patients. Although more than half of the patients in both age groups experienced DWIR, a significant reduction in DWI lesion volume was only observed in younger patients.
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Affiliation(s)
- Satoshi Takaishi
- Department of Neurology and Neurovascular therapy, St Marianna University School of Medicine Toyoko Hospital, Kawasaki, Kanagawa, Japan
| | - Toshihiro Ueda
- Department of Neurology and Neurovascular therapy, St Marianna University School of Medicine Toyoko Hospital, Kawasaki, Kanagawa, Japan
| | - Noriko Usuki
- Department of Neurology and Neurovascular therapy, St Marianna University School of Medicine Toyoko Hospital, Kawasaki, Kanagawa, Japan
| | - Kentaro Tatsuno
- Department of Neurology and Neurovascular therapy, St Marianna University School of Medicine Toyoko Hospital, Kawasaki, Kanagawa, Japan
| | - Tomohide Yoshie
- Department of Neurology and Neurovascular therapy, St Marianna University School of Medicine Toyoko Hospital, Kawasaki, Kanagawa, Japan
| | - Yoshihisa Yamano
- Department of Neurology, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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Gharaibeh K, Aladamat N, Mierzwa AT, Rao R, Alhajala H, Al Kasab S, Anadani M, Burgess R, Zaidi S, Jumaa M. Blood Pressure after Successful Endovascular Therapy: A Systematic Review and Meta-Analysis of Randomized Control Trials. Ann Neurol 2024; 95:858-865. [PMID: 38481016 DOI: 10.1002/ana.26907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/01/2024] [Accepted: 03/01/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE There are limited data evaluating the optimum blood pressure (BP) goal post mechanical thrombectomy (MT) and its effect on outcomes of patients with large vessel occlusions (LVO). The objective of this study was to compare the efficacy and safety of intensive versus conventional BP control after reperfusion with MT via a systematic review and meta-analysis of randomized controlled trials (RCTs). METHODS We searched PubMed and Embase to obtain articles related to BP control post MT through September 2023. The primary outcome was functional independence (modified Rankin Scale [mRS] 0-2) at 3 months, while secondary outcomes included excellent outcome (mRS 0-1), symptomatic intracranial hemorrhage (sICH), and mortality. RESULTS Four RCTs with 1,566 patients (762 randomized into intensive BP control vs. 806 randomized into conventional BP control) were included. Analysis showed that there was a lower likelihood of functional independence (mRS 0-2: odds ratio [OR]: 0.68, 95% confidence interval [CI] 0.51-0.91, p = 0.009) in the more intensive treatment group compared with the conventional treatment group. There was no statistically significant difference in achieving excellent outcome (mRS0-1: OR: 0.82, 95% CI: 0.63-1.07; p = 0.15), risk of sICH or mortality. INTERPRETATION This systematic review and meta- analysis Indicates that in patients who achieved successful MT for acute ischemic stroke with LVO, intensive BP control was associated with a lower likelihood of functional independence at 3 months without significant difference in likelihood of achieving excellent outcome, sICH risk, or mortality. ANN NEUROL 2024;95:858-865.
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Affiliation(s)
- Khaled Gharaibeh
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
| | - Nameer Aladamat
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Adam T Mierzwa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
| | - Rahul Rao
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
| | - Hisham Alhajala
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
| | - Sami Al Kasab
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Mohammad Anadani
- Department of Neurosciences, Intent Medical Group, Northshore University Neurosciences Institute, Arlington Heights, IL, USA
| | - Richard Burgess
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Syed Zaidi
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
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Hashimoto H, Maruo T, Kimoto Y, Nakamura M, Fujinaga T, Nakamura H, Ushio Y. The association between diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score and the outcome following mechanical thrombectomy of anterior circulation occlusion. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
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Zhai G, Song J, Yu N, Guo C, Liu S, Yue C, Yang D, Xie D, Liu X, Yu S, Lei L. Predictors of Mechanical Thrombectomy for Anterior Circulation Emergent Large-Vessel Occlusion in the Older Adults. Clin Appl Thromb Hemost 2023; 29:10760296231184219. [PMID: 37386776 DOI: 10.1177/10760296231184219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Few studies have reported the clinical outcomes of older adult patients with acute anterior circulation large-vessel occlusion (LVO) who underwent mechanical thrombectomy (MT). Therefore, we investigated the safety, functional outcomes, and predictors of MT for anterior circulation LVO in older adults. We enrolled patients with acute anterior circulation LVO from May 2018 to October 2021 in this retrospective study. Patients were divided into older (≥80 years) and young (<80 years) groups. Multivariable logistic regression analyses determined the safety, functional outcomes, and predictors of MT for anterior circulation LVO. We divided 1182 patients with acute ischemic stroke into young (18-79 years; 1028 patients) and older (≥80 years; 154 patients) groups. Compared with the young group, the older group had more unfavorable functional outcomes and increased mortality (P = .003). In the older adult patients, lower initial NIHSS score and higher ASPECTS were correlated with good outcomes. On the contrary, higher initial NIHSS score and lower ASPECTS were related to increased mortality. No difference was detected in symptomatic intracranial hemorrhage within 48 h between two groups. Increasing age was associated with lower rates of favorable functional outcomes and higher mortality rates. The lower initial NIHSS score combined with the higher ASPECTS may predict functional outcomes post-thrombectomy in older adults.
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Affiliation(s)
- Guojie Zhai
- Department of Neurology, Suzhou Ninth People's Hospital, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Nizhen Yu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dahong Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiang Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuye Yu
- Department of Neurology, Suzhou Ninth People's Hospital, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, China
| | - Lei Lei
- Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang, China
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Yang H, Lin D, Lin X, Wu Y, Yi T, Chen W. Outcomes and CT Perfusion Thresholds of Mechanical Thrombectomy for Patients With Large Ischemic Core Lesions. Front Neurol 2022; 13:856403. [PMID: 35720105 DOI: 10.3389/fneur.2022.856403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To explore the clinical prognosis and factors after mechanical thrombectomy (MT) in patients with large cerebral infarction assessed by computed tomographic perfusion (CTP)and the optimal threshold of cerebral blood flow (CBF) for estimating ischemic core. Methods We analyzed data from the anterior circulation database of our hospital (August 2018-June 2021). Multivariate logistic regression analyses identified the predictors of clinical outcomes for patients with large baseline infarcts (>50 ml) assessed by the MIStar software. The receiver operating characteristic (ROC) analysis was used to explore the cutoff value of factors. Results The present study included one hundred thirty-seven patients with large baseline infarcts. Moreover, 23 (16.8%) patients achieved functionally independent outcomes, and 50 (36.5%) patients died at 90 days. A total of 20 (14.7%) patients had symptomatic intracranial hemorrhage (sICH). The multivariable analysis showed that higher age and larger core volume were independent of poor outcomes. The cutoff value of core volume was 90 ml, and the age was 76 years. Hypertension and rt-PA treatment were independent factors of sICH. Higher age and larger ischemic volume were independent risk factors of mortality. Conclusions Mechanical thrombectomy can be applied in patients with large ischemic core volumes. Patients older than 76 years with large cores (>90 ml) are unlikely to benefit from MT. These findings may be helpful in selecting patients with large baseline infarcts to be treated by MT. The threshold of CBF < 30% is the independent factor, and this is worth evaluating in future studies to find the optimal threshold of CBF.
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Affiliation(s)
- Hongchao Yang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Dinglai Lin
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Xiaohui Lin
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Yanmin Wu
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
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Duloquin G, Ferrigno M, Hassen WB, Kyheng M, Bricout N, Boulouis G, Seners P, Labreuche J, Turc G, Naggara O, Cordonnier C, Henon H, Pasi M. Pre-treatment lesional volume in older stroke patients treated with endovascular treatment. Int J Stroke 2022; 17:1085-1092. [PMID: 35225745 DOI: 10.1177/17474930211068657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies in the general stroke population treated with endovascular treatment (EVT) reported that higher pre-treatment lesional volumes were independently associated with poor neurological outcome and functional dependence after stroke. However, it has been not evaluated in older patients. AIM We test the association between the pre-treatment lesional volume on diffusion-weighted magnetic resonance imaging and relevant outcome measures in older adults with stroke treated with EVT. METHODS We included consecutive older adults with stroke (⩾80 years old) treated with EVT in two academic comprehensive stroke centers. The association between pre-treatment lesional volume and relevant outcome measures (poor outcome (modified Rankin scale 4-6), 3-month mortality and symptomatic intracerebral hemorrhage (sICH)) was evaluated using univariate and multivariable models. RESULTS Five hundred seventy-nine patients were included (mean age: 85.6 ± 4.1, median lesional volume was 10 ml; interquartile range: 3-30 ml). Pre-treatment lesional volume was associated with poor functional outcome (adjusted odds ratio (aOR): 1.87, 95% confidence interval (CI): 1.60-2.20, for +1 logarithmic increase of lesional volume), 3-month mortality (aOR: 1.50, CI: 1.28-1.76), and sICH (aOR: 1.67, CI: 1.27-2.20). A threshold lesional volume >35 ml predicted 90% of patients with poor functional outcome and a cut-off >51 ml predicted 90% of patients dead at 3 months. CONCLUSIONS Pre-treatment lesional volume might contribute, in association with other relevant clinical features, to the selection of older stroke patients who will benefit from EVT.
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Affiliation(s)
- Gauthier Duloquin
- EA7460, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University Hospital of Dijon, University of Burgundy, Dijon, France
| | - Marc Ferrigno
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Wagih Ben Hassen
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Maéva Kyheng
- Département de Biostatistiques, CHU Lille, Lille, France.,University of Lille, CHU Lille, ULR 2694-METRICS: évaluation des technologies de santé et des pratiques médicales, Lille, France
| | | | - Grégoire Boulouis
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Pierre Seners
- Université de Paris, Inserm U1266, GHU Paris Psychiatrie et Neurosciences (Department of Neurology), FHU NeuroVasc, Paris, France
| | | | - Guillaume Turc
- Université de Paris, Inserm U1266, GHU Paris Psychiatrie et Neurosciences (Department of Neurology), FHU NeuroVasc, Paris, France
| | - Olivier Naggara
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Charlotte Cordonnier
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Hilde Henon
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Marco Pasi
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
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7
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Jiang Q, Wang H, Ge J, Hou J, Liu M, Huang Z, Guo Z, You S, Cao Y, Xiao G. Mechanical thrombectomy versus medical care alone in large ischemic core: An up-to-date meta-analysis. Interv Neuroradiol 2022; 28:104-114. [PMID: 33990150 PMCID: PMC8905077 DOI: 10.1177/15910199211016258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE We compared outcomes and adverse events of thrombectomy versus medical management in acute ischemic stroke (AIS) patients with baseline large infarct core. METHODS We searched Ovid MEDLINE(R) ALL, Cochrane Library Clinical Controlled Trials and EMBASE from inception to January 2021 for studies comparing thrombectomy and medical management alone in AIS patients who had ASPECTS <=7 or ischemic core volume >=50 ml. Imaging modalities to valuate ASPECTS and core volume were without restriction. The functional outcome was measured by mRS (modified Rankin Scale) score 0-2 at 90 days or discharge. The safety end point included the rates of mortality and sICH (symptomatic intracranial hemorrhage) or PH2 (parenchymal hematoma type 2). RESULTS Fourteen studies with a total of 2547 patients (thrombectomy n = [1197]; medical care alone [n = 1350]) fulfilled our criteria. As for patients with low ASPECTS, pooled results indicated a higher odds of good functional outcome (OR = 3.47; 95% CI 1.99 to 6.07; P < 0.0001, I2=66%) and a lower risk of mortality (OR = 0.62; 95% CI 0.46 to 0.83; P = 0.001, I2=32%) in thrombectomy group compared with no thrombectomy group, but the risk of sICH or PH2 did not differ between two groups. As for patients with large core volume, both functional outcome and safety end point between two groups showed no statistically significant difference. CONCLUSION Thrombectomy remained safe and effective by careful selection in patients with low ASPECTS. More studies were warranted to explore contraindications for mechanical thrombectomy in AIS patients, especially in patients with large core volume.
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Affiliation(s)
| | | | | | | | | | - Zhichao Huang
- Zhichao Huang, Department of Neurology, Second Affiliated Hospital of Soochow University, No. 1055, Sanxiang Road, 215004 Suzhou, Jiangsu, China.
| | | | | | | | - Guodong Xiao
- Guodong Xiao, Department of Neurology, Second Affiliated Hospital of Soochow University, No. 1055, Sanxiang Road, 215004 Suzhou, Jiangsu, China.
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8
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Regenhardt RW, Turner AC, Hirsch JA, Young MJ, Alotaibi NM, Stapleton CJ, Patel AB, Leslie-Mazwi TM, Rost NS, Etherton MR. Sex-specific differences in presentations and determinants of outcomes after endovascular thrombectomy for large vessel occlusion stroke. J Neurol 2022; 269:307-315. [PMID: 34052896 PMCID: PMC8628020 DOI: 10.1007/s00415-021-10628-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/16/2021] [Accepted: 05/26/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Sex-specific differences in ischemic stroke outcomes are prevalent. We sought to investigate sex differences in the determinants of reperfusion and functional outcomes after endovascular thrombectomy (EVT) for emergent large vessel occlusion ischemic stroke (ELVO). METHODS Patients presenting to a single referral center with an anterior circulation ELVO that underwent EVT from 2011 to 2019 were included in this retrospective analysis. Sex differences in history, presentation, adequate reperfusion (TICI 2b-3), and 90-day good outcome [delta modified Rankin Scale (mRS) ≤ 2 from pre-stroke] were examined. Multivariable logistic regression analyses were performed to assess sex-specific associations with outcomes. RESULTS Three hundred and eighty-one consecutive ELVO patients were identified. Women (N = 193) were older (75 vs 64 years, p < 0.0001), had more pre-stroke disability (17% vs 9%, p = 0.032), more atrial fibrillation (41% vs 30%, p = 0.033), but less carotid atherosclerosis (8% vs 16%, p = 0.027). Rates of TICI 2b-3 and good outcome were similar between sexes. Carotid atherosclerosis (OR 0.315, 95% CI 0.130, 0.762) and dissection (OR 0.124, 95% CI 0.027, 0.569) independently decreased the odds of TICI 2b-3 among men but not women. Older age, more severe stroke, and not achieving TICI 2b-3 independently decreased the odds of good outcome among both sexes, while prior stroke (OR 0.258, 95% CI 0.083, 0.797) and hemorrhagic transformation (OR 0.111, 0.021, 0.592) were determinants exclusive to men. CONCLUSION In a real-world analysis of ELVO stroke patients treated with EVT, we found that despite advanced age and more pre-stroke disability, women have comparable reperfusion rates and functional outcomes compared to men. Sex-specific determinants of reperfusion and functional outcome were identified that require further study.
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Affiliation(s)
- Robert W Regenhardt
- Neurology, Massachusetts General Hospital, 55 Fruit St, WAC-7-721, Boston, MA, USA. .,Neurosurgery, Massachusetts General Hospital, 55 Fruit St, WAC-7-721, Boston, MA, USA.
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9
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Wu X, Payabvash S, Matouk CC, Lev MH, Wintermark M, Sanelli P, Gandhi D, Malhotra A. Cost-effectiveness of endovascular thrombectomy in patients with low Alberta Stroke Program Early CT Scores (< 6) at presentation. J Neurosurg 2021; 135:1645-1655. [PMID: 33962378 DOI: 10.3171/2020.9.jns202965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/15/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The utility of endovascular thrombectomy (EVT) in patients with acute ischemic stroke, large vessel occlusion (LVO), and low Alberta Stroke Program Early CT Scores (ASPECTS) remains uncertain. The objective of this study was to determine the health outcomes and cost-effectiveness of EVT versus medical management in patients with ASPECTS < 6. METHODS A decision-analytical study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT-treated patients compared to medical management. The study was performed over a lifetime horizon with a societal perspective in the US setting. RESULTS The incremental cost-effectiveness ratios were $412,411/QALY and $1,022,985/QALY for 55- and 65-year-old groups in the short-term model. EVT was the long-term cost-effective strategy in 96.16% of the iterations and resulted in differences in health benefit of 2.21 QALYs and 0.79 QALYs in the 55- and 65-year-old age groups, respectively, equivalent to 807 days and 288 days in perfect health. EVT remained the more cost-effective strategy when the probability of good outcome with EVT was above 16.8% or as long as the good outcome associated with the procedure was at least 1.6% higher in absolute value than that of medical management. EVT remained cost-effective even when its cost exceeded $100,000 (threshold was $108,036). Although the cost-effectiveness decreased with age, EVT was cost-effective for 75-year-old patients as well. CONCLUSIONS This study suggests that EVT is the more cost-effective approach compared to medical management in patients with ASPECTS < 6 in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with nonreperfusion.
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Affiliation(s)
- Xiao Wu
- Departments of1Radiology and Biomedical Imaging and
| | | | - Charles C Matouk
- Departments of1Radiology and Biomedical Imaging and
- 2Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael H Lev
- 3Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Max Wintermark
- 4Department of Radiology, Stanford University, Palo Alto, California
| | - Pina Sanelli
- 5Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; and
| | - Dheeraj Gandhi
- 6Department of Radiology, Neurology and Neurosurgery, University of Maryland, Baltimore, Maryland
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10
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Bing F, Berger I, Fabry A, Moroni AL, Casile C, Morel N, M'Biene S, Guellerin J, Pignal-Jacquard C, Vadot W, Rodier G, Delory T, Jund J. Intra- and inter-rater consistency of dual assessment by radiologist and neurologist for evaluating DWI-ASPECTS in ischemic stroke. Rev Neurol (Paris) 2021; 178:219-225. [PMID: 34785042 DOI: 10.1016/j.neurol.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To estimate the intra -and inter-rater consistency of radiologist and neurologist working in pairs attributing DWI-ASPECTS (Diffusion Alberta Stroke Program Early CT Score) in patients with acute middle cerebral artery ischemic stroke referred for mechanical thrombectomy, intravenous thrombolysis or bridging therapy. METHODS Five neurologists and 5 radiologists working in pairs and in hour period scored independently and in two reading sessions anonymized DWI-ASPECTS of 80 patients presenting with acute anterior ischaemic stroke in our center. We measured agreement between pairs using intraclass correlation coefficients (ICCs). A Fleiss kappa was used for dichotomized (0-6;7-10) and trichotomized (0-3;4-6;7-10) ASPECTS. The interrater distribution of the score in the trichotomized (0-3;4-6;7-10) ASPECTS was calculated. We determined the interrater (Cohen kappa) and intrarater (Fleiss kappa) agreement on the ASPECTS regions. RESULTS The average DWI-ASPECTS was 6.35 (SD±2.44) for the first reading, and 6.47 (SD±2.44) for the second one. The ICC was 0.853 (95%CI, 0.798-0.896) for the interrater, and 0.862 (95%CI, 0.834-0.885) for the intrarater evaluation. Kappa coefficients were high for dichotomized (k=0.75) and trichotomized (k=0.64) ASPECTS. Evaluators agreement on the ASPECTS category (0-3), (4-6) and (7-10) was 88, 76 and 93% respectively. The anatomic region infarcted was well identified (k=0.70-0.77), except for the internal capsula (k=0.57). Interrater agreement was fair for M5 (k=0.37), moderate for internal capsula (0.52) and substantial for the other regions (0.60-0.79). CONCLUSIONS Reliability of DWI-ASPECTS is good when determined by radiologist and neurologist working in pairs, which corresponds to our current clinical practice. However, discrepancies are possible for cut-off determination, which may impact the indication of thrombectomy, and for the determination of the exact infarcted region. Agreement to propose category (4-6) is lower than for (0-3) and (8-10) ASPECTS categories.
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Affiliation(s)
- F Bing
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France.
| | - I Berger
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - A Fabry
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - A-L Moroni
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - C Casile
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - N Morel
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - S M'Biene
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - J Guellerin
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - C Pignal-Jacquard
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - W Vadot
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - G Rodier
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - T Delory
- Clinical Research Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - J Jund
- Medical Information and Evaluation Unit (SIEM), CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
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11
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Zaidat OO, Liebeskind DS, Jadhav AP, Ortega-Gutierrez S, Nguyen TN, Haussen DC, Yavagal DR, Froehler MT, Jahan R, Nogueira RG, Yao TL, Alenzi BA, Bushnaq S, Mueller-Kronast NH. Impact of Age and Alberta Stroke Program Early Computed Tomography Score 0 to 5 on Mechanical Thrombectomy Outcomes: Analysis From the STRATIS Registry. Stroke 2021; 52:2220-2228. [PMID: 34078106 PMCID: PMC8240495 DOI: 10.1161/strokeaha.120.032430] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: This study investigates clinical outcomes after mechanical thrombectomy in adult patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) of 0 to 5. Methods: We included data from the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) from patients who underwent mechanical thrombectomy within 8 hours of symptom onset and had available ASPECTS data adjudicated by an independent core laboratory. Angiographic and clinical outcomes were collected, including successful reperfusion (modified Thrombolysis in Cerebral Infarction ≥2b), functional independence (modified Rankin Scale score 0–2), 90-day mortality, and symptomatic intracranial hemorrhage at 24 hours. Outcomes were stratified by ASPECTS scores and age. Results: Of the 984 patients enrolled, 763 had available ASPECTS data. Of these patients, 57 had ASPECTS of 0 to 5 with a median age of 63 years (interquartile range, 28–100), whereas 706 patients had ASPECTS of 6 to 10 with a median age of 70 years of age (interquartile range, 19–100). Ten patients had ASPECTS of 0 to 3 and 47 patients had ASPECTS of 4 to 5 at baseline. Successful reperfusion was achieved in 85.5% (47/55) in the ASPECTS of 0 to 5 group. Functional independence was achieved in 28.8% (15/52) in the ASPECTS of 0 to 5 versus 59.7% (388/650) in the 6 to 10 group (P<0.001). Mortality rates were 30.8% (16/52) in the ASPECTS of 0 to 5 and 13.4% (87/650) in the 6 to 10 group (P<0.001). sICH rates were 7.0% (4/57) in the ASPECTS of 0 to 5 and 0.9% (6/682) in the 6 to 10 group (P<0.001). No patients aged >75 years with ASPECTS of 0 to 5 (0/12) achieved functional independence versus 44.8% (13/29) of those age ≤65 (P=0.005). Conclusions: Patients <65 years of age with large core infarction (ASPECTS 0–5) have better rates of functional independence and lower rates of mortality compared with patients >75 years of age. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239640.
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Affiliation(s)
- Osama O Zaidat
- Neuroscience Institute, St Vincent Mercy Hospital, Toledo, OH (O.O.Z., S.B.)
| | - David S Liebeskind
- Neurovascular Imaging Research Core and Stroke Center, Department of Neurology (D.S.L.), University of California Los Angeles
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J.)
| | - Santiago Ortega-Gutierrez
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa Health Care, Carver College of Medicine (S.O.-G.)
| | - Thanh N Nguyen
- Division of Interventional Neuroradiology and Interventional Neurology, Boston Medical Center, MA (T.N.N.)
| | - Diogo C Haussen
- Department of Neurology, Emory University, Atlanta, GA (D.C.H., R.G.N.)
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.T.F.)
| | - Reza Jahan
- Department of Radiology (R.J.), University of California Los Angeles
| | - Raul G Nogueira
- Department of Neurology, Emory University, Atlanta, GA (D.C.H., R.G.N.)
| | - Tom L Yao
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y.)
| | - Bader A Alenzi
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus (B.A.A.)
| | - Saif Bushnaq
- Neuroscience Institute, St Vincent Mercy Hospital, Toledo, OH (O.O.Z., S.B.)
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12
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Mazighi M, Thomalla G. Endovascular Therapy for Patients With Large Ischemic Strokes: Does Age Matter? Stroke 2021; 52:2229-2231. [PMID: 34078104 DOI: 10.1161/strokeaha.120.033884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mikael Mazighi
- Department of Neurology, Lariboisière Hospital, Research and Training Center for Cerebrovascular Disease, Fondation Rothschild Hospital, Université de Paris (M.M.)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf (G.T.)
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13
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Sojka M, Szmygin M, Pyra K, Tarkowski P, Luchowski P, Wojczal J, Drelich-Zbroja A, Jargiełło T. Predictors of outcome after mechanical thrombectomy for acute ischemic stroke in patients aged ≥90 years. Clin Neurol Neurosurg 2020; 200:106354. [PMID: 33172718 DOI: 10.1016/j.clineuro.2020.106354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/19/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has established its role as a first-line treatment of acute ischemic stroke due to large vessel occlusions (LVO). However, patients older than 85 or even 80 years of age are commonly excluded from large randomized controlled stroke studies as this group was found to be associated with significantly poorer clinical outcome and increased mortality compared to younger patients. The aim of this study was to evaluate clinical and procedural factors associated with clinical outcome and mortality among nonagenarians with acute ischemic stroke treated with mechanical thrombectomy. MATERIALS AND METHODS This retrospective, single-center study was conducted on 38 patients with LVO treated with MT. Clinical features including baseline results, radiological imaging, procedural details and outcome results were documented and evaluated. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS) and after 3 months (mRS). RESULTS The rate of successful recanalization (TICI ≥2b) was 84.2 % (32/38). Symptomatic intracranial hemorrhage (sICH) was observed in 3 (7.9 %) patients. After 90 days, the mortality rate was 47.4 %. Favorable clinical outcome (mRs 0-2) was regained in 28.9 % of the patients (11/38). Poor clinical outcome (mRs<2) was observed in 9 patients (23.7 %). CONCLUSION Very elderly patients with LVO should not be excluded from MT even if prognosis for good clinical outcome in this age group remains low and the procedure is more challenging. Long-term outcome is predicted by stroke severity (baseline NIHSS and occluded vessel) and hospital arrival time.
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Affiliation(s)
- Michał Sojka
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland
| | - Maciej Szmygin
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland.
| | - Krzysztof Pyra
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland
| | - Piotr Tarkowski
- Medical University of Lublin, Department of Radiology and Nuclear Medicine, Poland
| | - Piotr Luchowski
- Medical University of Lublin, Department of Neurology, Poland
| | - Joanna Wojczal
- Medical University of Lublin, Department of Neurology, Poland
| | - Anna Drelich-Zbroja
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland
| | - Tomasz Jargiełło
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland
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14
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Ahn Y, Kim SK, Baek BH, Lee YY, Lee HJ, Yoon W. Predictors of Catastrophic Outcome after Endovascular Thrombectomy in Elderly Patients with Acute Anterior Circulation Stroke. Korean J Radiol 2020; 21:101-107. [PMID: 31920033 PMCID: PMC6960312 DOI: 10.3348/kjr.2019.0431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/22/2019] [Indexed: 11/15/2022] Open
Abstract
Objective Avoiding a catastrophic outcome may be a more realistic goal than achieving functional independence in the treatment of acute stroke in octogenarians. This study aimed to investigate predictors of catastrophic outcome in elderly patients after an endovascular thrombectomy with an acute anterior circulation large vessel occlusion (LVO). Materials and Methods Data from 82 patients aged ≥ 80 years, who were treated with thrombectomy for acute anterior circulation LVO, were analyzed. The association between clinical/imaging variables and catastrophic outcomes was assessed. A catastrophic outcome was defined as a modified Rankin Scale score of 4–6 at 90 days. Results Successful reperfusion was achieved in 61 patients (74.4%), while 47 patients (57.3%) had a catastrophic outcome. The 90-day mortality rate of the treated patients was 15.9% (13/82). The catastrophic outcome group had a significantly lower baseline diffusion-weighted imaging-Alberta stroke program early CT score (DWI-ASPECTS) (7 vs. 8, p = 0.014) and a longer procedure time (42 minutes vs. 29 minutes, p = 0.031) compared to the non-catastrophic outcome group. Successful reperfusion was significantly less frequent in the catastrophic outcome group (63.8% vs. 88.6%, p = 0.011) compared to the non-catastrophic outcome group. In a binary logistic regression analysis, DWI-ASPECTS (odds ratio [OR], 0.709; 95% confidence interval [CI], 0.524–0.960; p = 0.026) and successful reperfusion (OR, 0.242; 95% CI, 0.071–0.822; p = 0.023) were independent predictors of a catastrophic outcome. Conclusion Baseline infarct size and reperfusion status were independently associated with a catastrophic outcome after endovascular thrombectomy in elderly patients aged ≥ 80 years with acute anterior circulation LVO.
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Affiliation(s)
- Younsu Ahn
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Seul Kee Kim
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Byung Hyun Baek
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Yun Young Lee
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Hyo Jae Lee
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Woong Yoon
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea.
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15
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Özdemir AÖ, Eryıldız ES, Akarsu FG, Kocabaş ZU, Aykaç Ö. The role of ASPECTs in patient selection for endovascular therapy – CTA source images versus noncontrast CT. J Clin Neurosci 2020; 73:195-200. [DOI: 10.1016/j.jocn.2019.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 08/28/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
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16
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Deb-Chatterji M, Pinnschmidt H, Flottmann F, Leischner H, Broocks G, Alegiani A, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G. Predictors of independent outcome of thrombectomy in stroke patients with large baseline infarcts in clinical practice: a multicenter analysis. J Neurointerv Surg 2020; 12:1064-1068. [DOI: 10.1136/neurintsurg-2019-015641] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/27/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022]
Abstract
ObjectiveTo analyze outcome and its predictors after endovascular treatment (ET) in stroke patients suffering from large vessel occlusion with large pre-treatment infarct cores defined by an Alberta Stroke Program Early CT Score (ASPECTS) <6.MethodsWe analyzed data from an industry-independent, multicenter, prospective registry (German Stroke Registry – Endovascular Treatment) which enrolled consecutive patients treated by ET (June 2015–April 2018) with different devices. Multivariate logistic regression analyses identified predictors of independent outcome (IO) defined as a modified Rankin Scale (mRS) 0–2, and mortality at 90 days in patients with ASPECTS <6.ResultsOf 1700 patients included in the analysis, 152 (8.9%) had a baseline ASPECTS <6. Of these, 33 patients (21.6%) achieved IO, and 68 (44.7%) were dead at 90 days. A lower age, lower baseline National Institutes of Health Stroke Scale (NIHSS) score, and successful recanalization (defined as modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) were predictors of IO. Successful recanalization had the strongest association with IO (OR 7.0, 95% CI 1.8 to 26.8). Pre-treatment parameters predicting IO were age <70 years (sensitivity 0.79, specificity 0.69) and NIHSS <12 (0.57 and 0.94). A higher age, a pre-stroke mRS score >1, and failed recanalization were predictors of death.ConclusionsA substantial proportion of stroke patients with an ASPECTS <6 can achieve independence after thrombectomy, in particular, if they are younger, have only moderate baseline stroke symptoms, and no relevant pre-stroke disability. These results may encourage considering thrombectomy in low ASPECTS patients in clinical practice until randomized trials are available.
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17
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Raoult H, Lassalle MV, Parat B, Rousseau C, Eugène F, Vannier S, Evain S, Le Bras A, Ronziere T, Ferre JC, Gauvrit JY, Laviolle B. DWI-Based Algorithm to Predict Disability in Patients Treated with Thrombectomy for Acute Stroke. AJNR Am J Neuroradiol 2020; 41:274-279. [PMID: 32001446 DOI: 10.3174/ajnr.a6379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/14/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The reasons for poor clinical outcome after thrombectomy for acute stroke, concerning around half of all patients, are misunderstood. We developed a hierarchic algorithm based on DWI to better identify patients at high risk of disability. MATERIALS AND METHODS Our single-center, retrospective study included consecutive patients with acute ischemic stroke who underwent thrombectomy for large anterior artery occlusion and underwent pretreatment DWI. The primary outcome was the mRS at 3 months after stroke onset. Multivariable regression was used to identify independent clinical and imaging predictors of poor prognosis (mRS > 2) at 3 months, and a hierarchic algorithm predictive of disability was developed. RESULTS A total of 149 patients were analyzed. In decreasing importance, DWI lesion volume of >80 mL, baseline NIHSS score of >14, age older than 75 years, and time from stroke onset to groin puncture of >4 hours were independent predictors of poor prognosis. The predictive hierarchic algorithm developed from the multivariate analysis predicted the risk of disability at 3 months for up to 100% of patients with a high predictive value. The area under the receiver operating characteristic curve was 0.87. CONCLUSIONS The DWI-based hierarchic algorithm we developed is highly predictive of disability at 3 months after thrombectomy and is easy to use in routine practice.
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Affiliation(s)
- H Raoult
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | | | - B Parat
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | - C Rousseau
- Clinical Pharmacology (C.R., B.L.), Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Clinique de Rennes, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - F Eugène
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | | | - S Evain
- Departments of Neurology (S.E.)
| | - A Le Bras
- Radiology (A.L.B.), Centre Hospitalier Universitaire Bretagne Atlantique, Vannes, France
| | | | - J C Ferre
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | - J Y Gauvrit
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | - B Laviolle
- Clinical Pharmacology (C.R., B.L.), Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Clinique de Rennes, Centre Hospitalier Universitaire Rennes, Rennes, France
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18
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Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Mendes Pereira V, Gralla J, Fischer U. Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0-5. Stroke 2020; 50:880-888. [PMID: 30827193 PMCID: PMC6430594 DOI: 10.1161/strokeaha.118.023465] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.
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Affiliation(s)
- Johannes Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Panagiotis Chaloulos-Iakovidis
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Leonidas Panos
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Patrik Michel
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Laurent Pierot
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | - Matthias Gawlitza
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | | | | | - Jan Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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19
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Long-term outcome changes after mechanical thrombectomy for anterior circulation acute ischemic stroke. J Neurol 2019; 267:1026-1034. [DOI: 10.1007/s00415-019-09670-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 12/11/2022]
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Kim MS, Kim GS. Single Centre Experience on Decision Making for Mechanical Thrombectomy Based on Single-Phase CT Angiography by Including NCCT and Maximum Intensity Projection Images - A Comparison with Magnetic Resonance Imaging after Non-Contrast CT. J Korean Neurosurg Soc 2019; 63:188-201. [PMID: 31658804 PMCID: PMC7054116 DOI: 10.3340/jkns.2019.0131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/01/2019] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this study was to suggest that computed tomography angiography (CTA) is valuable as the only preliminary examination for mechanical thrombectomy (MT). MT after single examination of CTA including non-contrast computed tomography (NCCT) and maximum intensity projection (MIP) improves door-to-puncture time as well as results in favorable outcomes.
Methods A total of 157 patients who underwent MT at Dong Kang Medical Center from April 2015 to March 2019 were divided into two groups based on the examination performed prior to MT : CTA group who underwent CTA with NCCT and MIP, and NCCT+magnetic resonance image (MRi) group who underwent MRI including perfusion images after NCCT. In the two groups, time to CTA imaging or NCCT+MRi imaging after symptom onset, and time to arterial puncture and reperfusion were characterized as time-related outcomes. The evaluation of vascular recanalization after MT was defined as a modified thrombolysis in cerebral infarction (mTICI) scale. National Institutes of Health Stroke Scale (NIHSS) was assessed at the time of the visit to the emergency room and modified Rankin Scale (mRS) was assessed after 90 days.
Results Typically, there were 34 patients in the CTA group and 33 patients in the NCCT+MRi group. A significantly shorter delay for door-to-puncture time was observed (mean, 86±22.1 vs. 176±47.5 minutes; p<0.01). Also, a significantly shorter door-to-imege time in the CTA group was observed (mean, 13±6.8 vs. 93±30.8 minutes; p<0.01). Moreover, a significantly shorter onset-to-puncture time was observed (mean, 195±128.0 vs. 314±157.6 minutes; p<0.01). Reperfusion result of mTICI ≥2b was 100% (34/34) in the CTA group and 94% (31/33) in the NCCT+MRi group, and mTICI 3 in 74% (25/34) in the CTA group and 73% (24/33) in the NCCT+MRi group. Favorable functional outcomes (mRS score ≤2 at 90 days) were 68% (23/34) in the CTA group and 60% (20/33) in the NCCT+MRi group.
Conclusion A single-phase CTA including NCCT and MIP images was performed as a single preliminary examination, which led to a reduction in the time of the procedure and resulted in good results of prognosis. Consequently, it is concluded that this method is of sufficient value as the only preliminary examination for decision making.
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Affiliation(s)
- Myeong Soo Kim
- Department of Neurosurgery, Dong Kang Medical Center, Ulsan, Korea
| | - Gi Sung Kim
- Department of Radiology, Dong Kang Medical Center, Ulsan, Korea
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Farouil G, Sablot D, Leibinger F, Van Damme L, Coll F, Gaillard N, Ibanez M, Smadja P, Benayoun L, Dutray A, Tardieu M, Nguyen Them L, Bonnec JM, Jurici S, Bensalah ZM, Olivier N, Desmond L, Fadat B, Bertrand JL, Mas J, Akouz A, Allou T, Mourand I, Ferraro-Allou A, Dumitrana A, Aptel S, Arquizan C, Costalat V, Bonafe A. Mechanical Recanalization after Transfer from a Distant Primary Stroke Center: Effectiveness and Future Directions. J Stroke Cerebrovasc Dis 2019; 28:104368. [PMID: 31537417 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/23/2019] [Accepted: 08/21/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Little is known about the effectiveness of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) admitted to a primary stroke center (PSC). The aim of this study was to assess EVT effectiveness after transfer from a PSC to a distant (156 km apart; 1.5 hour by car) comprehensive stroke center (CSC), and to discuss perspectives to improve access to EVT, if indicated. PATIENTS AND METHOD Analysis of the data collected in a 6-year prospective registry of patients admitted to a PSC for AIS due to LVO and selected for transfer to a distant CSC for EVT. The rate of transfer, futile transfer, EVT, reperfusion (thrombolysis in cerebral infarction score ≥2b-3), and relevant time measures were determined. RESULTS Among the 529 patients eligible, 278 (52.6%) were transferred and 153 received EVT (55% of transferred patients) followed by reperfusion in 115 (overall reperfusion rate: 21.7%). Median times (interquartile range) were: 90 minutes (76-110) for PSC-door-in to PSC-door-out, 88 minutes (65-104) for PSC-door-out to CSC-door-in, 262 minutes (239-316) for PSC-imaging to reperfusion, and 393 minutes (332-454) for symptom onset to reperfusion. At 3 months, rates of favorable outcome (modified Rankin Scale 0-2) were not significantly different between patients eligible for EVT (42.4%), transferred patients (49.1%) and patients who underwent EVT (34.1%). DISCUSSION AND CONCLUSIONS Our study suggests that transfer to a distant CSC is associated with reduced access to early EVT. These results argue in favor of on-site EVT at high volume PSCs that are distant from the CSC.
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Affiliation(s)
| | - Denis Sablot
- Regional Health Agency of Occitanie, Montpellier, France; Neurology Department, Perpignan, France.
| | | | | | | | - Nicolas Gaillard
- Neurology Department, Perpignan, France; Neurology Department, Montpellier, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Julie Mas
- Neurology Department, Perpignan, France
| | - Aziz Akouz
- Intensive Care Unit, Perpignan, France; Emergency Department, Perpignan, France
| | | | | | | | | | | | | | | | - Alain Bonafe
- Radiology Department, Perpignan, France; Neuroradiology Department, Montpellier, France
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22
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Cagnazzo F, Derraz I, Dargazanli C, Lefevre PH, Gascou G, Riquelme C, Bonafe A, Costalat V. Mechanical thrombectomy in patients with acute ischemic stroke and ASPECTS ≤6: a meta-analysis. J Neurointerv Surg 2019; 12:350-355. [DOI: 10.1136/neurintsurg-2019-015237] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 11/03/2022]
Abstract
BackgroundIt is uncertain whether mechanical thrombectomy (MT) increases the probability of a good outcome (modified Rankin Scale (mRS) 0–2) in patients with Alberta Stroke Program Early CT Score (ASPECTS) 0–6.ObjectiveTo assess the impact of MT in patients with pretreatment ASPECTS 0–6.MethodsAccording to PRISMA guidelines, we performed a systematic search of three databases for series of patients with ASPECTS 0–6 treated by MT. Random-effects meta-analysis was used to pool the following: rate of mRS 0–2 at 3 months follow-up, symptomatic intracranial hemorrhage (sICH), and mortality rates.ResultsWe included 17 studies and 1378 patients with ASPECTS 0–6 (1194 MT, 184 medical management). The rate of mRS 0–2 was 30.1% and 3.2% after MT and medical management, respectively. MT gave higher odds of mRS 0–2 (OR 4.76, p=0.01). Patients with ASPECTS 6 and 5 had comparable rates of good outcome (37.7% and 33.3%, respectively). Overall, the rate of mRS 0–2 was 17.1% in patients with ASPECTS 0–4: 22.1% and 13.9% of patients with ASPECTS 4 and 0–3 were functionally independent, respectively. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b–3) gave higher odds of mRS 0–2 than unsuccessful reperfusion (OR 5.2, p=0.001). The MT group tended to have lower odds of sICH compared with the controls (OR 0.48, p=0.06). Patients aged <70 years had higher rates of mRS 0–2 than those aged >70 years (40.3% vs 16.2%).ConclusionsPatients with ASPECTS 0–6may benefit from MT. Successful reperfusion increases the probability of 3-month functional independence without increasing the risk of sICH. Patients with ASPECTS 5 and 6 have comparable outcomes. MT can still enable approximately one in four patients with ASPECTS 4 to be independent, whereas only 14% of subjects with ASPECTS 0–3 regain a good functional outcome.
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23
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Acute ischemic stroke patients with diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score ≤ 5 can benefit from endovascular treatment: a single-center experience and literature review. Neuroradiology 2019; 61:451-459. [PMID: 30725121 PMCID: PMC6431332 DOI: 10.1007/s00234-019-02177-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/22/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE The recommendation strength of the guidelines for mechanical thrombectomy among patients with large pre-treatment core infarct is weak. We evaluated the safety and outcome of endovascular treatment for acute ischemic stroke with diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) ≤ 5. METHODS Data on acute ischemic stroke patients with DWI-ASPECTS ≤ 5 who underwent endovascular treatment within 6 h, or presented an arterial spin labeling-DWI (ASL-DWI) mismatch within 12 h, at our center were retrospectively collected. We report the clinical characteristics and outcome of every patient, and review the relevant literature. RESULTS Among the 19 patients who were enrolled, all experienced successful reperfusion, and 10 achieved a favorable outcome (modified Rankin scale (mRS) ≤ 2). Two patients presented with symptomatic intracranial hemorrhage (sICH); both of them had a poor outcome (mRS > 2). CONCLUSION Acute ischemic stroke patients with large DWI lesions caused by large vessel occlusion can achieve a favorable clinical outcome with endovascular treatment if recanalization is performed within 6 h, or after 6 h in case of an ASL-DWI mismatch.
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24
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Fuhrer H, Schönenberger S, Niesen WD, Seide S, Meyne J, Gerner ST, Vollmuth C, Beck C, Meckel S, Schocke M, Wodarg F, Huttner HB, Möhlenbruch MA, Kieser M, Ringleb P, Neugebauer H. Endovascular stroke treatment's impact on malignant type of edema (ESTIMATE). J Neurol 2018; 266:223-231. [PMID: 30470996 DOI: 10.1007/s00415-018-9127-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke and large vessel occlusion, the prognosis has improved tremendously since the implementation of endovascular thrombectomy (EVT). The effect of EVT on the incidence of malignant middle cerebral artery infarctions (MMI) has not been studied before. METHODS ESTIMATE, a multicenter retrospective study, evaluates data of ischemic stroke patients with occlusion in the anterior circulation in the years of 2007-2015 comparing three treatment options (no therapy; IV-TPA; IV-TPA plus EVT or EVT only). Primary endpoint of the study was the incidence of MMI on follow-up imaging and mortality rates. Secondary endpoints were functional outcome, further clinical and imaging data. Logistic and Cox-regression models with a propensity score weighting approach were applied to evaluate differences between treatment groups. RESULTS In 2161 patients over 9 years, EVT reduced the MMI rates significantly: patients without acute stroke treatment had increased odds for MMI of 1.57 [95% confidence interval (CI) 1.49-1.65]. In contrast, after treatment with IV-TPA, only we observed an OR of 0.88 (95% CI 0.83-0.94, p < 0.001), and after EVT an OR of 0.80 (95% CI 0.76-0.85, p < 0.001). This was more pronounced in larger pretreatment infarctions (ASPECTS < 5, p < 0.01). IV-TPA also lowers the MMI rates but not to the same extent. EVT-treated patients had increased survival rates (p < 0.05) and the best functional outcome at discharge. CONCLUSIONS The findings of this study illustrate that occurrence of MMI and mortality rates was significantly reduced in patients treated with EVT.
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Affiliation(s)
- Hannah Fuhrer
- Department of Neurology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.
| | - Silvia Schönenberger
- Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
| | - Svenja Seide
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Christoph Vollmuth
- Department of Neurology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Christopher Beck
- Department of Neuroradiology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Department of Nuclear medicine, University Hospital Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Stephan Meckel
- Department of Neuroradiology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
| | - Michael Schocke
- Department of Neuroradiology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Fritz Wodarg
- Department of Neuroradiology, University Hospital Kiel, Arnold-Heller-Straße 9, 24105, Kiel, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
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Mourand I, Malissart P, Dargazanli C, Nogue E, Bouly S, Gaillard N, Boukriche Y, Corti L, Picot MC, Beaufils O, Chbicheb M, Sablot D, Bonafe A, Costalat V, Arquizan C. A Regional Network Organization for Thrombectomy for Acute Ischemic Stroke in the Anterior Circulation; Timing, Safety, and Effectiveness. J Stroke Cerebrovasc Dis 2018; 28:259-266. [PMID: 30442556 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/19/2018] [Accepted: 09/27/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) in association with intravenous thrombolysis is recommended for treatment of acute ischemic stroke (AIS), with large vessel occlusion (LVO) in the anterior circulation. Because MT is only available in comprehensive stroke centers (CSC), the challenge of stroke organization is to ensure equitable access to the fastest endovascular suite. Our aim was to evaluate the feasibility, efficacy, and safety of MT in patients initially managed in 1 CSC (mothership), compared with patients first managed in primary stroke center (PSC), and then transferred to the CSC for MT (drip-and-ship). METHODS We retrospectively analyzed 179 consecutive patients (93 in the mothership group and 86 in the drip-and-ship group), with AIS secondary to LVO in the anterior cerebral circulation and a clinical-radiological mismatch (NIHSS ≥ 8 and DWI-ASPECT score ≥5), up to 6 hours after symptoms onset. We evaluated 3-month functional modified Rankin scale (mRS), periprocedural time management, mortality, and symptomatic intracranial haemorrhage (sICH). RESULTS Despite significant longer process time in the drip-and-ship group, mRS ≤ 2 at 3 months (39.8% versus 44.1%, P = .562), Thrombolysis in cerebral infarction 2b-3 (85% versus 78%, P = .256), and sICH (7.0% versus 9.7%, P = .515) were similar in both group regardless of baseline clinical or radiological characteristics. After multivariate logistic regression, the predictive factors for favorable outcome were age (odds ratio [OR] -5years= 1.32, P < .001), initial NIHSS (OR -5points = 1.59, P = .010), absence of diabetes (OR = 3.35, P = .075), and the delay magnetic resonance imagining-puncture (OR -30min = 1.16, P = .048). CONCLUSIONS Our study showed encouraging results from a regional protocol of MT comparing patients transferred from PSC or brought directly in CSC.
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Affiliation(s)
- Isabelle Mourand
- Department of Neurology, CHRU, Gui de Chauliac Hospital, Montpellier, France.
| | - Pauline Malissart
- Department of Neurology, CHRU, Gui de Chauliac Hospital, Montpellier, France.
| | - Cyril Dargazanli
- Department of Neuroradiology, University Hospital Center, Montpellier, France.
| | - Erika Nogue
- Medical Information Department, University Hospital Center, Montpellier, France.
| | - Stephane Bouly
- Department of Neurology, Caremeau Hospital, Nimes, France.
| | - Nicolas Gaillard
- Department of Neurology, CHRU, Gui de Chauliac Hospital, Montpellier, France; Department of Neurology, Hospital of Perpignan, France.
| | | | - Lucas Corti
- Department of Neurology, CHRU, Gui de Chauliac Hospital, Montpellier, France.
| | | | - Olivier Beaufils
- Department of Emergency, University Hospital Center, Montpellier, France.
| | | | - Denis Sablot
- Department of Neurology, Hospital of Perpignan, France.
| | - Alain Bonafe
- Department of Neuroradiology, University Hospital Center, Montpellier, France.
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Center, Montpellier, France.
| | - Caroline Arquizan
- Department of Neurology, CHRU, Gui de Chauliac Hospital, Montpellier, France.
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26
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Phan K, Saleh S, Dmytriw AA, Maingard J, Barras C, Hirsch JA, Kok HK, Brooks M, Chandra RV, Asadi H. Influence of ASPECTS and endovascular thrombectomy in acute ischemic stroke: a meta-analysis. J Neurointerv Surg 2018; 11:664-669. [PMID: 30415223 DOI: 10.1136/neurintsurg-2018-014250] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Prompt revascularization of the ischemic penumbra following an acute ischemic event (AIS) has established benefit within the literature. However, use of the semi-quantitative Alberta Stroke Program Early CT Score (ASPECTS) to evaluate patient suitability for revascularization has been inconsistent in patient risk stratification and selection. OBJECTIVE To conduct a meta-analysis to evaluate the available evidence for a clinically valid ASPECTS threshold in assessment of suitability for revascularization following AIS. METHODS Two independent reviewers searched Medline (Ovid) and Cochrane Central Register of Systematic Reviews databases for studies appraising outcomes of endovascular thrombectomy (EVT) in relation to a variably-defined preoperative ASPECTS. RESULTS A total of 13 articles were included. The pooled good outcome proportion after EVT was 41.4% (95% CI 36.4% to 46.6%; p<0.001), with subjective study-specific definitions of favorable and unfavorable subgroup outcomes of 49.7% (95% CI 44.2% to 55.3%; I2=76.5%; p<0.001) and 33.2% (95% CI 28.5% to 38.3%; I2=33.16%), respectively. Objective trichotomization into low (0-4), intermediate (5-7), and high (8-10) subgroups yielded pooled good outcome proportions of 17.1% (95% CI 6.8% to 36.8%; I2=64.24%; p=0.039), 35.7% (95% CI 30.5% to 41.3%; I2=23.11%; p=0.245), and 49.7% (95% CI 44.2% to 55.3%; I2=76.5%; p<0.001) for low, intermediate, and high ASPECTS, respectively. CONCLUSIONS A subjectively favorable ASPECTS is associated with significantly better outcomes after EVT than an unfavorable ASPECTS, regardless of the cut-off used. EVT is unlikely to be useful in patients with an objectively low ASPECTS and is likely to be useful for those with high ASPECTS; findings in patients with intermediate ASPECTS were equivocal.
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Affiliation(s)
- Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia
| | - Serag Saleh
- NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia
| | - Adam A Dmytriw
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada
| | - Julian Maingard
- Interventional Neuroradiology, Austin Health, Heidelberg, Victoria, Australia
| | - Christen Barras
- University of Adelaide, Adelaide, South Australia, Australia
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hong Kuan Kok
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Mark Brooks
- Interventional Neuroradiology, Austin Health, Heidelberg, Victoria, Australia
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Health, Clayton, Victoria, Australia
- Department of Imaging, Monash University, Clayton, Victoria, Australia
| | - Hamed Asadi
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
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Slawski DE, Salahuddin H, Shawver J, Kenmuir CL, Tietjen GE, Korsnack A, Zaidi SF, Jumaa MA. Mechanical Thrombectomy in Elderly Stroke Patients with Mild-to-Moderate Baseline Disability. INTERVENTIONAL NEUROLOGY 2018; 7:246-255. [PMID: 29765394 DOI: 10.1159/000487333] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/31/2018] [Indexed: 11/19/2022]
Abstract
Background The number of elderly patients suffering from ischemic stroke is rising. Randomized trials of mechanical thrombectomy (MT) generally exclude patients over the age of 80 years with baseline disability. The aim of this study was to understand the efficacy and safety of MT in elderly patients, many of whom may have baseline impairment. Methods Between January 2015 and April 2017, 96 patients ≥80 years old who underwent MT for stroke were selected for a chart review. The data included baseline characteristics, time to treatment, the rate of revascularization, procedural complications, mortality, and 90-day good outcome defined as a modified Rankin Scale (mRS) score of 0-2 or return to baseline. Results Of the 96 patients, 50 had mild baseline disability (mRS score 0-1) and 46 had moderate disability (mRS score 2-4). Recanalization was achieved in 84% of the patients, and the rate of symptomatic hemorrhage was 6%. At 90 days, 34% of the patients had a good outcome. There were no significant differences in good outcome between those with mild and those with moderate baseline disability (43 vs. 24%, p = 0.08), between those aged ≤85 and those aged > 85 years (40.8 vs. 26.1%, p = 0.19), and between those treated within and those treated beyond 8 h (39 vs. 20%, p = 0.1). The mortality rate was 38.5% at 90 days. The Alberta Stroke Program Early CT Score (ASPECTS) and the National Institutes of Health Stroke Scale (NIHSS) predicted good outcome regardless of baseline disability (p < 0.001 and p = 0.009, respectively). Conclusion Advanced age, baseline disability, and delayed treatment are associated with sub-optimal outcomes after MT. However, redefining good outcome to include return to baseline functioning demonstrates that one-third of this patient population benefits from MT, suggesting the real-life utility of this treatment.
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Affiliation(s)
- Diana E Slawski
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | | | | | - Cynthia L Kenmuir
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Syed F Zaidi
- University of Toledo Medical Center, Toledo, Ohio, USA
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28
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Ohta T, Morimoto M, Okada K, Fukuda M, Onishi H, Masahira N, Matsuoka T, Tsuno T, Takemura M. Mechanical Thrombectomy in Anterior Circulation Occlusion Could Be More Effective than Medical Management Even in Low DWI-ASPECTS Patients. Neurol Med Chir (Tokyo) 2018; 58:156-163. [PMID: 29479041 PMCID: PMC5929913 DOI: 10.2176/nmc.oa.2017-0203] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study was to investigate whether patients with low preoperative Diffusion-weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) could benefit from mechanical thrombectomy for acute anterior circulation occlusion. This was a retrospective, non-blinded, cohort study. From September 2012 to August 2016, 83 consecutive patients of acute anterior circulation occlusion were treated with thrombectomy using second-generation devices or medical management. The DWI-ASPECTS was scored after the first MRI. Patient characteristics and clinical outcomes were compared between the treatment groups. Significant dependence was defined as a modified Rankin scale score ≥3 at 90 days. As a result, 33 patients underwent mechanical thrombectomy and 50 received medical management. In the mechanical thrombectomy group, the variable of lower DWI-ASPECTS (5, 4–6 vs. 8, 7–8, P < 0.001), especially ≤6, was significantly associated with poor prognosis. However, compared with patients of DWI-ASPECTS ≤ 6 who received medical management, there were significantly fewer patients with poor outcomes in thrombectomy (dependent in 11 of 15 vs. 23 of 23, respectively; P = 0.019). Although patients with lower pretreatment DWI-ASPECTS could benefit less from thrombectomy, their outcomes were still better than medical management. Therefore, mechanical thrombectomy could be considered in some patients with low pretreatment DWI-ASPECTS.
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Affiliation(s)
- Tsuyoshi Ohta
- Department of Neurosurgery, Kochi Health Sciences Center
| | | | - Kenji Okada
- Department of Neurosurgery, Kochi Health Sciences Center
| | - Maki Fukuda
- Department of Neurosurgery, Kochi Health Sciences Center
| | - Hirokazu Onishi
- Department of Emergency Medicine, Kochi Health Sciences Center
| | | | | | - Takaya Tsuno
- Department of Neurosurgery, Kochi Health Sciences Center
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29
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Barral M, Lassalle L, Dargazanli C, Mazighi M, Redjem H, Blanc R, Rodesch G, Lapergue B, Piotin M. Predictors of favorable outcome after mechanical thrombectomy for anterior circulation acute ischemic stroke in octogenarians. J Neuroradiol 2018; 45:211-216. [PMID: 29470997 DOI: 10.1016/j.neurad.2018.01.055] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 12/04/2017] [Accepted: 01/14/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Mechanical thrombectomy for anterior circulation large vessel occlusion (LVO) improves functional outcome at three months. This therapeutic approach is the new gold standard, with a benefit being also observed in elderly patients. However, data are limited in this heterogeneous and fragile population. The objectives of this study were, first, to describe outcome after mechanical thrombectomy in a representative group of patients over 80. Second, to evaluate factors associated with a favorable functional outcome after thrombectomy for anterior circulation LVO in elderly patients (aged≥80 years). METHODS A total of 169 patients with anterior circulation LVO referred for an endovascular treatment were included. Primary outcome evaluated functional outcome at three months. Multivariable analysis was performed to identify prognostic factors in elderly patients with pre-stroke mRS≤3. RESULTS Overall, 25.34% of patients (43/169) were functionally independent at three months (mRS≤2) and 16.57% (28/169) had a moderate functional disability (mRS=3). Mortality rate was 33.14% (56/169). At 24h, 7.1% of patients (12/169) had symptomatic hemorrhage. Male gender (P=0.033), low initial NIHSS (P=0.037), higher DWI-ASPECTS (P=0.022) and use of intravenous thrombolysis (IVT) (P=0.0193) were associated with a better functional outcome. CONCLUSIONS There is no reason to withhold mechanical thrombectomy on the basis of age alone. Small infarct core, low NIHSS, male gender and use of IVT are associated with a better functional outcome.
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Affiliation(s)
- Matthias Barral
- Department of Interventional Neuroradiology, Rothschild Foundation, 25 rue Manin, 75940 Paris, France.
| | - Louis Lassalle
- Department of Radiology, Hopital Antoine Beclere, 157 Rue de la Porte de Trivaux, 92140 Clamart, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, Rothschild Foundation, 25 rue Manin, 75940 Paris, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, 25 rue Manin, 75940 Paris, France; Laboratory of Vascular Translational Science, INSERM U 1148, CHU Bichat, Bâtiment Inserm 46, rue Henri Huchard, 75877 Paris Cedex 18, France
| | - Hocine Redjem
- Department of Interventional Neuroradiology, Rothschild Foundation, 25 rue Manin, 75940 Paris, France
| | - Raphael Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation, 25 rue Manin, 75940 Paris, France
| | - Georges Rodesch
- Department of Diagnostic and Interventional Neuroradiology, Hopital Foch, 40, Rue Worth, 92150 Suresnes, France
| | - Bertrand Lapergue
- Division of Neurology, Stroke Center, Hopital Foch, 40, Rue Worth, 92150 Suresnes, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, 25 rue Manin, 75940 Paris, France
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30
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Koizumi S, Kimura T, Shojima M, Inoue T. Initial Attempt to Select Patients for Mechanical Thrombectomy Using Noncontrast Computed Tomography and Symptom-Based Criteria: Single-Center Experience. World Neurosurg 2018; 112:e581-e587. [PMID: 29410336 DOI: 10.1016/j.wneu.2018.01.091] [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: 10/25/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND In the treatment of acute ischemic stroke (AIS), patients need to be selected for mechanical thrombectomy (MT) in the acute phase. Selection criteria vary, however, depending on the patient's situation. This study investigated the effectiveness of a noncontrast computed tomography and symptom-based protocol for selecting patients for MT. METHODS This retrospective study included 20 patients with AIS. The first 8 patients (earlier group) were screened by magnetic resonance imaging (MRI). Among the later 12 patients, MRI was deliberately skipped in 9, and major vessel occlusion was confirmed by digital subtraction angiography after meeting 4 criteria: 1) hospital arrival within 90 minutes from onset; 2) National Institutes of Health Stroke Scale score 9-25; 3) history or presence of atrial fibrillation; and 4) Alberta Stroke Program Early CT Score of 9-10. The clinical outcomes and time course were compared. RESULTS Among the later period group, 9 of 12 patients skipped MRI-based confirmation of large vessel occlusion. They underwent the direct angiography protocol, which had a 78% (7/9) positive predictive value for identifying large-vessel occlusion. In this group, National Institutes of Health Stroke Scale scores on the next day had significantly improved (median -8 points) compared with those at admission. Good functional outcome did not differ between the groups at 3 months. CONCLUSIONS Noncontrast computed tomography and symptom-based selection of MT to treat AIS can be useful for achieving better neurologic recovery in a subgroup of patients. This approach could broaden the use of MT.
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Affiliation(s)
- Satoshi Koizumi
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan; Department of Neurosurgery, The University of Tokyo, Tokyo, Japan.
| | - Toshikazu Kimura
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Masaaki Shojima
- Department of Neurosurgery, The University of Tokyo, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
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Smith AG, Rowland Hill C. Imaging assessment of acute ischaemic stroke: a review of radiological methods. Br J Radiol 2017; 91:20170573. [PMID: 29144166 DOI: 10.1259/bjr.20170573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Acute ischaemic stroke is the second largest cause of death worldwide and a cause of major physical and psychological morbidity. Current evidence based treatment includes intravenous thrombolysis (IVT) and mechanical thrombectomy (MT), both requiring careful patient selection and to be administered as quickly as possible within a limited time window from symptom onset. Imaging plays a crucial role identifying patients who may benefit from MT or IVT whilst excluding those that may be harmed. For IVT, imaging must as a minimum exclude haemorrhage, stroke mimics and provide an estimate of non-viable brain. For MT, imaging must in addition detect and characterize intra-arterial thrombus and assess the intra and extracranial arterial architecture. More advanced imaging techniques may be used to assess more accurately the volume of non-viable and potentially salvageable brain tissue. It is highly likely that further research will identify patients who would benefit from treatment beyond currently accepted time windows for IVT (4.5 h) and MT (6 h) and patients with an unknown time of symptom onset. Current evidence indicates that best outcomes are achieved when treatment is instituted as soon as possible after symptom onset. A rapid, efficient imaging pathway including interpretation is fundamental to achieving the best outcomes. This review summarizes current techniques for imaging assessment of acute stroke, highlighting strengths and limitations of each. The optimum pathway is a balance between diagnostic information, local resources, specialization and the time taken to acquire, process and interpret the data. As new evidence emerges, it is likely that the minimum required imaging data will change.
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Abstract
The Alberta Stroke Program Early CT score (ASPECTS) is a 10-point semiquantitative topographic scoring system developed for the assessment of early ischemic changes (EICs) on noncontrast-enhanced computed tomography (NCCT) in patients with acute ischemic stroke involving the middle cerebral artery (MCA) territory. One point is subtracted from a total score of 10, if an EIC is present in any part of each of the ASPECTS regions. Higher ASPECTS has been associated with better outcomes and a lower risk of symptomatic intracerebral hemorrhage. To date, there are still controversies regarding the utility of ASPECTS for selecting patients for intravenous and intra-arterial therapies. This article provides a comprehensive review regarding methodology, limitations, and interobserver reproducibility of ASPECTS, as well as application of ASPECTS in clinical care. The focus of this review is ASPECTS evaluation on NCCT. The application of ASPECTS on multimodal computed tomography and magnetic resonance imaging (MRI) is briefly described.
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Affiliation(s)
- Supada Prakkamakul
- *Department of Radiology, King Chulalongkorn Memorial Hospital the Thai Red Cross Society, Bangkok, Thailand †Division of Neurointervention, Texas Stroke Institute, Plano, TX
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Clinical Outcome of Mechanical Thrombectomy for Stroke in the Elderly. J Stroke Cerebrovasc Dis 2017; 26:582-588. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/10/2016] [Accepted: 11/24/2016] [Indexed: 11/19/2022] Open
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Kuntze Söderqvist Å, Andersson T, Wahlgren N, Kaijser M. Mechanical Thrombectomy in Acute Ischemic Stroke—Patients with Wake-Up Stroke and the Elderly May Benefit as Well. J Stroke Cerebrovasc Dis 2016; 25:2276-83. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.05.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/03/2015] [Accepted: 05/17/2016] [Indexed: 11/28/2022] Open
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Han M, Choi JW, Rim NJ, Kim SY, Suh HI, Lee KS, Hong JM, Lee JS. Cerebral infarct volume measurements to improve patient selection for endovascular treatment. Medicine (Baltimore) 2016; 95:e4702. [PMID: 27583902 PMCID: PMC5008586 DOI: 10.1097/md.0000000000004702] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients who have large cerebral infarctions may not be good candidates for endovascular treatment. Various methods for determining infarct volume have been used in clinical studies. We evaluated the effectiveness of several methods for measuring infarct volume, especially regarding futile outcomes despite endovascular treatment.Patients with acute ischemic stroke in unilateral anterior circulation territory who were treated with intra-arterial thrombectomy were included. For assessing infarct volume, the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) scoring system was applied to images obtained by noncontrast computed tomography (NCCT), postcontrast CT (PCCT), and diffusion-weighted imaging (DWI). DWI stroke volume was semiquantitatively measured with the manually outlined hyperintense lesion. Infarct core volume was calculated with a threshold apparent diffusion coefficient value of 600 × 10 mm/s. Intraclass correlation coefficients (ICC) were estimated to assess inter-reader reliability for ASPECTS scoring and DWI stroke volume. Receiver operating characteristic (ROC) curve analyses, and univariable and multivariable comparative analyses, were performed with each evaluation method to predict futile outcome (modified Rankin Scale score 5-6).The mean age of the included 79 patients was 65.1 ± 15.7 years. Among them, 55 (69.6%) patients demonstrated successful reperfusion after intra-arterial thrombectomy, but 34 (43.0%) patients had futile outcomes. Inter-reader agreement was excellent for measurement of the DWI stroke volume (ICC, 0.973), DWI ASPECTS (0.940), and PCCT ASPECTS (0.859), but was moderate for NCCT ASPECTS (0.694). Regarding prediction of futile outcomes, area under ROC curve was 0.551 on NCCT ASPECTS and it was significantly smaller than that in PCCT ASPECTS (area under ROC 0.651, P = 0.030), DWI ASPECTS (0.733, P = 0.003), DWI stroke volume (0.702, P = 0.022), and infarct core volume (0.702, P = 0.021). Besides old age and high National Institutes of Health Stroke Scale score on admission, MRI parameters such as DWI ASPECTS and infarct core volume indicating large volumes were independently associated with futile outcomes in multivariable analyses.DWI ASPECTS can be a good parameter predicting futility, which is easily measured and has high prediction power.
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Affiliation(s)
| | | | | | | | - Hong-Il Suh
- Department of Neurology, Ajou University School of Medicine and Hospital, Suwon, Republic of Korea
| | - Kyu Sun Lee
- Department of Neurology, Ajou University School of Medicine and Hospital, Suwon, Republic of Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine and Hospital, Suwon, Republic of Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine and Hospital, Suwon, Republic of Korea
- Correspondence: Jin Soo Lee, Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center; San 5, Woncheon-dong, Yeongtong-gu, Suwon, Kyungki-do 443-721, Korea (e-mail: )
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Marnat G, Mourand I, Eker O, Machi P, Arquizan C, Riquelme C, Ayrignac X, Bonafé A, Costalat V. Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study. AJNR Am J Neuroradiol 2016; 37:1281-8. [PMID: 26965467 DOI: 10.3174/ajnr.a4752] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/03/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Internal carotid artery dissection is a common cause of stroke in young adults. It may be responsible for tandem occlusion defined by a cervical steno-occlusive carotid wall hematoma associated with an intracranial large-vessel stroke. Intravenous thrombolysis is associated with a poor clinical outcome in these cases, and endovascular treatment has not been specifically evaluated to date. Our aim was to evaluate endovascular treatment technical and clinical efficiency in this specific occlusion topography, in comparison with treatment of isolated anterior circulation stroke. MATERIALS AND METHODS As part of our ongoing prospective stroke data base started in August 2009 (Prognostic Factors Related to Clinical Outcome Following Thrombectomy in Ischemic Stroke [RECOST] Study), we analyzed all carotid artery dissection tandem occlusion strokes and isolated anterior circulation occlusions. All patients were selected for endovascular treatment according to clinical-radiologic mismatch, NIHSS ≥ 7 and DWI-ASPECTS ≥5, within 6 hours after onset. For carotid artery dissection, the revascularization procedure consisted first of distal recanalization by a stent retriever in the intracranial vessel. Following assessment of the circle of Willis, internal carotid artery stent placement was only performed in case of insufficiency. Carotid artery dissection treatment efficacy, safety, and clinical outcome were compared with the results of the isolated anterior circulation occlusion cohort. RESULTS Two hundred fifty-eight patients with an anterior circulation stroke were analyzed, including 57 with tandem occlusions (22%); among them, 20 were carotid artery dissection-related occlusions (7.6%). The median age of patients with tandem occlusions with internal carotid dissection was 52.45 versus 66.85 years for isolated anterior circulation occlusion (P < .05); the mean initial NIHSS score was 17.53 ± 4.11 versus 17.55 ± 4.8 (P = .983). The median DWI-ASPECTS was 6.05 versus 6.64 (P = .098), and the average time from onset to puncture was 4.38 for tandem occlusions versus 4.53 hours in isolated anterior circulation occlusion (P = .704). Complication rates and symptomatic intracranial hemorrhage were comparable in both groups (5% versus 3%, P = .49). The duration of the procedure was significantly prolonged in case of tandem occlusion (80.69 versus 65.45 minutes, P = .030). Fourteen patients with carotid artery dissection (70%) had a 3-month mRS of ≤ 2, without a significant difference from patients with an isolated anterior circulation occlusion (44%, P = .2). Only 5 carotid artery dissections (25%) necessitated cervical stent placement. No early ipsilateral stroke recurrence was recorded, despite the absence of stent placement in 15 patients (75%) with carotid artery dissection. CONCLUSIONS Mechanical endovascular treatment of carotid artery dissection tandem occlusions is safe and effective compared with isolated anterior circulation occlusion stroke therapy. Hence, a more conservative approach with stent placement only in cases of circle of Willis insufficiency may be a reliable and safe strategy.
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Affiliation(s)
- G Marnat
- From the Department of Interventional and Diagnostic Neuroradiology (G.M.), Bordeaux University Hospital, Bordeaux, France
| | - I Mourand
- Departments of Neurology (I.M., C.A., X.A.)
| | - O Eker
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - P Machi
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - C Arquizan
- Departments of Neurology (I.M., C.A., X.A.)
| | - C Riquelme
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - X Ayrignac
- Departments of Neurology (I.M., C.A., X.A.)
| | - A Bonafé
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - V Costalat
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
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Kim SK, Yoon W, Park MS, Heo TW, Baek BH, Lee YY. Outcomes Are Not Different between Patients with Intermediate and High DWI-ASPECTS after Stent-Retriever Embolectomy for Acute Anterior Circulation Stroke. AJNR Am J Neuroradiol 2016; 37:1080-5. [PMID: 26767711 DOI: 10.3174/ajnr.a4663] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/23/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Questions remain as to what benefits embolectomy provides to patients presented with considerable early ischemic changes on baseline imaging studies. This study aimed to investigate the impact of the Alberta Stroke Program Early CT Score applied to DWI on treatment outcomes in patients with acute stroke undergoing stent-retriever embolectomy. MATERIALS AND METHODS We retrospectively analyzed the clinical and DWI data from 171 patients with acute anterior circulation stroke who were treated with stent-retriever embolectomy within 6 hours of symptom onset. DWI-ASPECTS scores were analyzed with the full scale or were dichotomized (4-6 versus 7-10). Patients with DWI-ASPECTS ≤3 were excluded from the study. Associations between outcome and clinical and radiologic factors were determined with a multivariate logistic regression analysis. A good outcome was defined as a modified Rankin Scale score of 0-2 at 3 months. RESULTS The median DWI-ASPECTS was 7 (interquartile range, 6-8). The rates of good outcome, symptomatic hemorrhage, and mortality were not different between high DWI-ASPECTS (scores of 7-10) and intermediate DWI-ASPECTS (scores of 4-6) groups. In patients with an intermediate DWI-ASPECTS, good outcome was achieved in 46.5% (20/43) of patients with successful revascularization, whereas no patients without successful revascularization had a good outcome (P = .016). In multivariate logistic regression analysis, independent predictors of good outcome were age and successful revascularization. CONCLUSIONS Our study suggested that there were no differences in outcomes between patients with a high DWI-ASPECTS and those with an intermediate DWI-ASPECTS who underwent stent-retriever embolectomy for acute anterior circulation stroke. Thus, patients with an intermediate DWI-ASPECTS otherwise eligible for endovascular therapy may not be excluded from stent-retriever embolectomy or stroke trials.
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Affiliation(s)
- S K Kim
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
| | - W Yoon
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
| | - M S Park
- Neurology (M.S.P.), Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - T W Heo
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
| | - B H Baek
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
| | - Y Y Lee
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
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Wahlgren N, Moreira T, Michel P, Steiner T, Jansen O, Cognard C, Mattle HP, van Zwam W, Holmin S, Tatlisumak T, Petersson J, Caso V, Hacke W, Mazighi M, Arnold M, Fischer U, Szikora I, Pierot L, Fiehler J, Gralla J, Fazekas F, Lees KR. Mechanical thrombectomy in acute ischemic stroke: Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN. Int J Stroke 2015; 11:134-47. [DOI: 10.1177/1747493015609778] [Citation(s) in RCA: 271] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The original version of this consensus statement on mechanical thrombectomy was approved at the European Stroke Organisation (ESO)-Karolinska Stroke Update conference in Stockholm, 16–18 November 2014. The statement has later, during 2015, been updated with new clinical trials data in accordance with a decision made at the conference. Revisions have been made at a face-to-face meeting during the ESO Winter School in Berne in February, through email exchanges and the final version has then been approved by each society. The recommendations are identical to the original version with evidence level upgraded by 20 February 2015 and confirmed by 15 May 2015. The purpose of the ESO-Karolinska Stroke Update meetings is to provide updates on recent stroke therapy research and to discuss how the results may be implemented into clinical routine. Selected topics are discussed at consensus sessions, for which a consensus statement is prepared and discussed by the participants at the meeting. The statements are advisory to the ESO guidelines committee. This consensus statement includes recommendations on mechanical thrombectomy after acute stroke. The statement is supported by ESO, European Society of Minimally Invasive Neurological Therapy (ESMINT), European Society of Neuroradiology (ESNR), and European Academy of Neurology (EAN).
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Affiliation(s)
- Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Tiago Moreira
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Michel
- Département des Neurosciences Cliniques, Lausanne, Switzerland
| | - Thorsten Steiner
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH, Kiel, Germany
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Turgut Tatlisumak
- Institute of Neuroscience and Physiology, Sahlgrenska Academy of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jesper Petersson
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
- Department of Neurology, Lund University, Lund, Sweden
| | - Valeria Caso
- Stroke Unit, Santa Maria Hospital, University of Perugia, Perugia, Italy
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Mikael Mazighi
- Pole Neurosensoriel Tête et Cou, Hôpital Lariboisière, Paris, France
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Istvan Szikora
- Department of Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Laurent Pierot
- Service de Radiologie, Hôpital Maison-Blanche, Reims, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Franz Fazekas
- Department of Neurology, Medical University Graz, Graz, Austria
| | - Kennedy R Lees
- Department of Cerebrovascular Medicine, University of Glasgow, Glasgow, Scotland, UK
- Acute Stroke Unit, Western Infirmary, Glasgow, Scotland, UK
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Slater LA, Coutinho JM, Gralla J, Nogueira RG, Bonafé A, Dávalos A, Jahan R, Levy E, Baxter BJ, Saver JL, Pereira VM. TICI and Age: What's the Score? AJNR Am J Neuroradiol 2015; 37:838-43. [PMID: 26611995 DOI: 10.3174/ajnr.a4618] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies have suggested that advanced age predicts worse outcome following mechanical thrombectomy. We assessed outcomes from 2 recent large prospective studies to determine the association among TICI, age, and outcome. MATERIALS AND METHODS Data from the Solitaire FR Thrombectomy for Acute Revascularization (STAR) trial, an international multicenter prospective single-arm thrombectomy study and the Solitaire arm of the Solitaire FR With the Intention For Thrombectomy (SWIFT) trial were pooled. TICI was determined by core laboratory review. Good outcome was defined as an mRS score of 0-2 at 90 days. We analyzed the association among clinical outcome, successful-versus-unsuccessful reperfusion (TICI 2b-3 versus TICI 0-2a), and age (dichotomized across the median). RESULTS Two hundred sixty-nine of 291 patients treated with Solitaire in the STAR and SWIFT data bases for whom TICI and 90-day outcome data were available were included. The median age was 70 years (interquartile range, 60-76 years) with an age range of 25-88 years. The mean age of patients 70 years of age or younger was 59 years, and it was 77 years for patients older than 70 years. There was no significant difference between baseline NIHSS scores or procedure time metrics. Hemorrhage and device-related complications were more common in the younger age group but did not reach statistical significance. In absolute terms, the rate of good outcome was higher in the younger population (64% versus 44%, P < .001). However, the magnitude of benefit from successful reperfusion was higher in the 70 years of age and older group (OR, 4.82; 95% CI, 1.32-17.63 versus OR 7.32; 95% CI, 1.73-30.99). CONCLUSIONS Successful reperfusion is the strongest predictor of good outcome following mechanical thrombectomy, and the magnitude of benefit is highest in the patient population older than 70 years of age.
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Affiliation(s)
- L A Slater
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging
| | - J M Coutinho
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging
| | - J Gralla
- Service of Neuroradiology (J.G.), Inselspital, University of Bern, Bern, Switzerland
| | - R G Nogueira
- Marcus Stroke and Neuroscience Center (R.G.N.), Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - A Bonafé
- Department of Neuroradiology (A.B.), Hôpital Gui-de-Chauliac, Montpellier, France
| | - A Dávalos
- Department of Neurosciences (A.D.), Hospital Universitario Germans Trias i Pujol, Barcelona, Spain
| | - R Jahan
- Division of Interventional Neuroradiology (R.J.)
| | - E Levy
- Toshiba Stroke and Vascular Research Center (E.L.), State University of New York at Buffalo, Buffalo, New York
| | - B J Baxter
- Department of Radiology (B.J.B.), Erlanger Hospital at the University of Tennessee, Chattanooga, Tennessee
| | - J L Saver
- Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - V M Pereira
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging Division of Neurosurgery (V.M.P.), Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Meckel S, Taschner C, ElSheikh S, Maurer CJ, Urbach H. [Mechanical thrombectomy for acute ischemic stroke : current evidence and open questions]. DER NERVENARZT 2015; 86:1226-35. [PMID: 26440630 DOI: 10.1007/s00115-015-4270-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine the importance of mechanical thrombectomy (MT) in the treatment of ischemic stroke. MATERIAL AND METHODS Analysis and comparison of randomized controlled trials (RCT) of MT versus i.v. thrombolysis (IVT) considering pathophysiological and logistic aspects. RESULTS The use of MT is more effective than IVT for internal carotid artery terminus (ICAT), M1 segment and tandem occlusions, i.e. proximal internal carotid artery (ICA) occlusion or stenosis, even in patients older than 75-80 years of age. Due to the small sample sizes this question cannot be answered for patients with M2 occlusions. It is still uncertain whether MT is needed in patients with a low National Institutes of Health stroke scale (NIHSS) score, whether IVT is needed before MT and what type of imaging should be performed. Approximately one third of eligible patients currently undergo MT in Germany. Results from RCTs with stent retrievers for patients with vertebrobasilar artery occlusions are lacking. CONCLUSION After becoming established as a first-line therapy for patients with ICAT, M1 segment and tandem occlusions, the effectiveness of MT with stent retrievers has to proven in patients with more distal occlusions, low NIHSS scores and even vertebrobasilar artery occlusions.
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Affiliation(s)
- S Meckel
- Klinik für Neuroradiologie, Uniklinik Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland.
| | - C Taschner
- Klinik für Neuroradiologie, Uniklinik Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland
| | - S ElSheikh
- Klinik für Neuroradiologie, Uniklinik Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland
| | - C J Maurer
- Klinik für Neuroradiologie, Uniklinik Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland
| | - H Urbach
- Klinik für Neuroradiologie, Uniklinik Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland
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Park JH, Han YM, Jang KS, Yoon WS, Jang DK, Park SK. Angiographic and Clinical Factors Related with Good Functional Outcome after Mechanical Thrombectomy in Acute Cerebral Artery Occlusion. J Korean Neurosurg Soc 2015; 58:192-6. [PMID: 26539260 PMCID: PMC4630348 DOI: 10.3340/jkns.2015.58.3.192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 07/17/2015] [Accepted: 08/04/2015] [Indexed: 01/19/2023] Open
Abstract
Objective The aim of this study is to investigate good prognostic factors for an acute occlusion of a major cerebral artery using mechanical thrombectomy. Methods Between January 2013 to December 2014, 37 consecutive patients with acute occlusion of a major cerebral artery treated by mechanical thrombectomy with stent retrievers were conducted. We analyzed clinical and angiographic factors retrospectively. The collateral flow and the result of recanalization were sorted by grading systems. Outcome was assessed by National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 90 days. We compared the various parameters between good and poor angiographic and clinical results. Results Twenty seven patients demonstrated good recanalization [Thrombolysis in Cerebral Infarction (TICI) 2b or 3] after thrombectomy. At the 90-day follow up, 19 patients had good (mRS, 0-2), 14 had moderate (3-4) and four had poor outcomes (5-6). The mRS of older patients (≥75 years) were poor than younger patients. Early recanalization, high Thrombolysis in Myocardial Infarction risk score, and low baseline NIHSS were closely related to 90-day mRS, whereas high TICI was related to both mRS and the decrease in the NIHSS. Conclusion NIHSS decreased markedly only when recanalization was successful. A good mRS was related to low initial NIHSS, good collateral, and early successful recanalization.
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Affiliation(s)
- Jong Hyuk Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Min Han
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyeong Sool Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wan Soo Yoon
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Kyu Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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To CY, Rajamand S, Mehra R, Falatko S, Badr Y, Richards B, Qahwash O, Fessler RD. Outcome of mechanical thrombectomy in the very elderly for the treatment of acute ischemic stroke: the real world experience. Acta Radiol Open 2015; 4:2058460115599423. [PMID: 26445678 PMCID: PMC4580118 DOI: 10.1177/2058460115599423] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 07/15/2015] [Indexed: 01/19/2023] Open
Abstract
Background Although initial studies of neuroendovascular intervention did not review benefit over intravenous thrombolytics (iv r-tPA), recent studies have suggested otherwise. Elderly patients (age ≥80 years) are typically excluded from clinical trials. Purpose To examine the utility of mechanical thrombectomy based on patient outcomes. Material and Methods All stroke-alert activations at our health system from January 2011 to June 2014 were examined. All patients aged ≥80 years who had undergone mechanical thrombectomy were identified. Clinical characteristics included physiologic imaging findings, use of intravenous thrombolytics, baseline and postoperative National Institute of Health Stroke Scale (NIHSS), thrombolysis in cerebral infarction scores (TICI), and discharge destination. Results Mean NIHSS on presentation was 18.2 (range, 6–31), and 13.3 (range, 3–30) post thrombectomy. Three (16.6%) patients received iv r-tPA, two (11.1%) had symptomatic intracranial hemorrhage. Eight (44.4%) died, eight (44.4%) were discharged to nursing homes, and two (11.7%) were discharged to inpatient rehab and subsequently home. Favorable outcome was achieved in five (27.7%) patients. Fourteen (77.7%) patients had physiologic imaging prior to intervention. Three (75%) of four patients who did not have physiologic imaging prior to thrombectomy died. Thirteen (66.6%) patients had TICI 3 recanalization. Conclusion Our study showed that although there remains a role of mechanical thrombectomy in the treatment of acute ischemic stroke in very elderly patients, it is associated with significant higher morbidity and mortality compared to younger patients, but should remain a very viable treatment option when quality of life is the most important consideration.
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Affiliation(s)
- Chiu Yuen To
- Providence Hospital and Medical Center, Southfield, MI, USA
| | - Sina Rajamand
- Providence Hospital and Medical Center, Southfield, MI, USA
| | - Ratnesh Mehra
- Providence Hospital and Medical Center, Southfield, MI, USA
| | | | - Yaser Badr
- Badr Medical Corperation, Los Angeles, CA, USA
| | - Boyd Richards
- Providence Hospital and Medical Center, Southfield, MI, USA
| | - Omar Qahwash
- St. John Hospital and Medical Center, Detroit, MI, USA
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Mortimer AM, Steinfort B, Faulder K, Harrington T. Delayed infarction following aneurysmal subarachnoid hemorrhage: Can the role of severe angiographic vasospasm really be dismissed? J Neurointerv Surg 2015; 8:802-7. [DOI: 10.1136/neurintsurg-2015-011854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 06/22/2015] [Indexed: 11/03/2022]
Abstract
BackgroundThe recent literature pertaining to delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage has downplayed the role of angiographic vasospasm. However, it is our hypothesis that angiographic vasospasm has a significant pathophysiological role in this disease. We undertook an observational radiographic study of patients who presented in a delayed manner (>72 h from ictus) with evidence of severe angiographic vasospasm on initial angiography in order to describe an apparent association between vasospasm and infarct location.MethodsThis was a retrospective study of consecutive patients treated at our unit. Initial, subsequent, and follow-up cross-sectional imaging with CT or MRI was analyzed in conjunction with initial angiography. Sites of angiographic narrowing, angiographic hypoperfusion, and subsequent sites of infarction were assessed.ResultsThirteen patients (6 women, 7 men) of mean age 49 years were assessed. Mean time to presentation was 6 days. All had severe angiographic vasospasm. Nine of the 13 patients suffered infarction; the infarcts in seven of the nine patients were large. There was correlation between sites of angiographic narrowing and infarction in all cases and eight of the nine cases showed angiographic hypoperfusion in a location corresponding to eventual infarct location.ConclusionsSevere angiographic vasospasm may be linked to infarction in patients who present late. These infarcts are mostly large despite maximal treatment. We question the notion that proximal vasospasm has a minor role in delayed ischemia.
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Distance to thrombus on MR angiography predicts outcome of middle cerebral artery occlusion treated with IV thrombolysis. Neuroradiology 2015; 57:991-7. [DOI: 10.1007/s00234-015-1558-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 07/01/2015] [Indexed: 10/23/2022]
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Helenius J, Henninger N. Leukoaraiosis Burden Significantly Modulates the Association Between Infarct Volume and National Institutes of Health Stroke Scale in Ischemic Stroke. Stroke 2015; 46:1857-63. [PMID: 25999386 DOI: 10.1161/strokeaha.115.009258] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The National Institutes of Health Stroke Scale (NIHSS) provides a reliable, quantitative measure of ischemic stroke severity and is predicted by the infarct size. We sought to determine whether leukoaraiosis severity affects the association between infarct size and NIHSS. METHODS NIHSS and diffusion-weighted imaging-defined infarct volumes from 312 prospectively enrolled patients with supratentorial, ischemic strokes were analyzed. Leukoaraiosis severity was graded according to the Fazekas scale and conceptually defined as absent (0; n=44), mild (1-2; n=106), moderate (3-4; n=105), and severe (5-6; n=57). ANCOVA was used to describe the effect of leukoaraiosis on the association between infarct volume and NIHSS. Multivariable linear regression models were constructed to assess whether the association of leukoaraiosis and infarct volume on NIHSS was independent of other clinically relevant covariates. RESULTS Overall, there was a significant correlation between the infarct volume and NIHSS (r=0.591; P<0.001). This correlation significantly attenuated with increasing leukoaraiosis severity from r=0.786 (P<0.001; absent leukoaraiosis) to r=0.498 (P<0.001; severe leukoaraiosis) and as shown by ANCOVA (P<0.001). Leukoaraiosis (coefficient, 0.107; 95% confidence interval, 0.036-0.179; P=0.016) and infarct volume (coefficient, 0.360; 95% confidence interval, 0.305-0.416; P<0.001) were independently associated with a greater NIHSS deficit in the fully adjusted multivariable model. CONCLUSIONS Leukoaraiosis significantly modulates the association between infarct volume and NIHSS. The clinical implications of these findings need further exploration in prospective studies but may be relevant to mitigate outcome differences in patients with stroke by aiding treatment decisions that rely on the NIHSS.
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Affiliation(s)
- Johanna Helenius
- From the Departments of Neurology (J.H., N.H.) and Psychiatry (N.H.), University of Massachusetts Medical School, Worcester
| | - Nils Henninger
- From the Departments of Neurology (J.H., N.H.) and Psychiatry (N.H.), University of Massachusetts Medical School, Worcester.
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