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Poli S, Grohmann C, Wenzel DA, Poli K, Tünnerhoff J, Nedelmann M, Fiehler J, Burghaus I, Lehmann M, Glauch M, Schadwinkel HM, Kalmbach P, Zeller J, Peters T, Eschenfelder C, Agostini H, Campbell BC, Fischer MD, Sykora M, Mac Grory B, Feltgen N, Kowarik M, Seiffge D, Strbian D, Albrecht M, Alzureiqi MS, Auffarth G, Bäzner H, Behnke S, Berberich A, Bode F, Bohmann FO, Cheng B, Czihal M, Danyel LA, Dimopoulos S, Pinhal Ferreira de Pinho JD, Fries FN, Gamulescu MA, Gekeler F, Gomez-Exposito A, Gumbinger C, Guthoff R, Hattenbach LO, Kellert L, Khoramnia R, Kohnen T, Kürten D, Lackner B, Laible M, Lee JI, Leithner C, Liegl R, Lochner P, Mackert M, Mbroh J, Müller S, Nagel S, Prasuhn M, Purrucker J, Reich A, Mundiyanapurath S, Royl G, Salchow DJ, Schäfer JH, Schlachetzki F, Schmack I, Thomalla G, Tieck Fernandez MP, Wakili P, Walter P, Wolf A, Wolf M, Bartz-Schmidt KU, Schultheiss M, Spitzer MS. Early REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION): Study protocol of a phase III trial. Int J Stroke 2024; 19:823-829. [PMID: 38591748 DOI: 10.1177/17474930241248516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
RATIONALE Meta-analyses of case series of non-arteritic central retinal artery occlusion (CRAO) indicate beneficial effects of intravenous thrombolysis when initiated early after symptom onset. Randomized data are lacking to address this question. AIMS The REperfusion therapy with intravenous alteplase for recovery of VISION in acute central retinal artery occlusion (REVISION) investigates intravenous alteplase within 4.5 h of monocular vision loss due to acute CRAO. METHODS This study is the randomized (1:1), double-blind, placebo-controlled, multicenter adaptive phase III trial. STUDY OUTCOMES Primary outcome is functional recovery to normal or mildly impaired vision in the affected eye defined as best-corrected visual acuity of the Logarithm of the Minimum Angle of Resolution of 0.5 or less at 30 days (intention-to-treat analysis). Secondary efficacy outcomes include modified Rankin Score at 90 days and quality of life. Safety outcomes include symptomatic intracranial hemorrhage, major bleeding (International Society on Thrombosis and Haemostasis definition) and mortality. Exploratory analyses of optical coherence tomography/angiography, ultrasound and magnetic resonance imaging (MRI) biomarkers will be conducted. SAMPLE SIZE Using an adaptive design with interim analysis at 120 patients, up to 422 participants (211 per arm) would be needed for 80% power (one-sided alpha = 0.025) to detect a difference of 15%, assuming functional recovery rates of 10% in the placebo arm and 25% in the alteplase arm. DISCUSSION By enrolling patients within 4.5 h of CRAO onset, REVISION uses insights from meta-analyses of CRAO case series and randomized thrombolysis trials in acute ischemic stroke. Increased rates of early reperfusion and good neurological outcomes in stroke may translate to CRAO with its similar pathophysiology. TRIAL REGISTRATION ClinicalTrials.gov: NCT04965038; EU Trial Number: 2023-507388-21-00.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Carsten Grohmann
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel A Wenzel
- Department of Ophthalmology, University of Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Max Nedelmann
- Department of Neurology, Regio Kliniken GmbH, Pinneberg, Germany
| | - Jens Fiehler
- Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Ina Burghaus
- Coordination Centre for Clinical Trials (KKS), Medical Faculty & Heidelberg University Hospital, Germany
| | - Monika Lehmann
- Coordination Centre for Clinical Trials (KKS), Medical Faculty & Heidelberg University Hospital, Germany
| | - Monika Glauch
- Center for Rare Diseases, University of Tübingen, Germany
| | - Hauke M Schadwinkel
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pia Kalmbach
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Julia Zeller
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Tobias Peters
- Department of Ophthalmology, University of Tübingen, Germany
| | | | | | - Bruce Cv Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - M Dominik Fischer
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, UK
- Nuffield Laboratory of Ophthalmology, University of Oxford, UK
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Brian Mac Grory
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Nicolas Feltgen
- Department of Ophthalmology, Universitätsspital Basel, Switzerland
| | - Markus Kowarik
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - David Seiffge
- Department of Neurology, University of Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | | | - Mohammad S Alzureiqi
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gerd Auffarth
- Department of Ophthalmology, University of Heidelberg, Germany
| | | | - Stefanie Behnke
- Department of Neurology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | | | - Felix Bode
- Department of Neurology, University Hospital Bonn, Germany
| | - Ferdinand O Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Czihal
- Medical Clinic and Policlinic IV, Division of Vascular Medicine, Ludwig Maximilian University (LMU), Munich, Germany
| | - Leon A Danyel
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | | | - Fabian N Fries
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | | | | | - Alexandra Gomez-Exposito
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | | | - Rainer Guthoff
- Department of Ophthalmology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | | | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Ramin Khoramnia
- Department of Ophthalmology, University of Heidelberg, Germany
| | - Thomas Kohnen
- Department of Ophthalmology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - David Kürten
- Department of Ophthalmology, University Hospital, RWTH Aachen University, Aachen, Germany
| | | | - Mona Laible
- Department of Neurology, University Hospital Ulm, Germany
| | - John-Ih Lee
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | - Christoph Leithner
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Raffael Liegl
- Department of Ophthalmology, University Hospital Bonn, Germany
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Marc Mackert
- Department of Ophthalmology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Susanne Müller
- Department of Neurology, University Hospital Ulm, Germany
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Germany
| | - Michelle Prasuhn
- Department of Ophthalmology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Jan Purrucker
- Department of Neurology, University of Heidelberg, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | | | - Georg Royl
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Daniel J Salchow
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan H Schäfer
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | | | - Ingo Schmack
- Department of Ophthalmology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria P Tieck Fernandez
- Department of Neurology & Stroke, University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Philip Wakili
- Department of Ophthalmology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | - Peter Walter
- Department of Ophthalmology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Armin Wolf
- Department of Ophthalmology, Klinik Sulzbach, Knappschaftsklinikum Saar, Germany
| | - Marc Wolf
- Department of Neurology, Klinikum Stuttgart, Germany
| | | | - Maximilian Schultheiss
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
- AugenChirurgie München, Eye Clinic Herzog Carl Theodor, Munich, Germany
| | - Martin S Spitzer
- Department of Ophthalmology, Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lange KS, Mourand I, Coget A, Menjot de Champfleur N, Ayrignac X, Arquizan C, Scheel M, Bohner G, Villringer K, Zagroun C, Siebert E, Danyel LA. Diffusion-weighted magnetic resonance imaging in early central retinal artery occlusion. Eur Stroke J 2023; 8:974-981. [PMID: 37997381 PMCID: PMC10683725 DOI: 10.1177/23969873231190716] [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: 06/02/2023] [Accepted: 07/12/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Restricted retinal diffusion (RDR) has recently been recognized as a frequent finding on standard diffusion-weighted imaging (DWI) in central retinal artery occlusion (CRAO). However, data on early DWI signal evolution are missing. PATIENTS AND METHODS Consecutive CRAO patients with DWI performed within 24 h after onset of visual impairment were included in a bicentric, retrospective cross-sectional study. Two blinded neuroradiologists assessed randomized DWI scans for the presence of retinal ischemia. RDR detection rates, false positive ratings, and interrater agreement were evaluated for predefined time groups. RESULTS Sixty eight CRAO patients (68.4 ± 16.8 years; 25 female) with 72 DWI scans (76.4% 3 T, 23.6% 1.5 T) were included. Mean time-delay between onset of CRAO and DWI acquisition was 13.4 ± 7.0 h. Overall RDR detection rates ranged from 52.8% to 62.5% with false positive ratings in 4.2%-8.3% of cases. RDR detection rates were higher in DWI performed 12-24 h after onset, when compared with DWI acquired within the first 12 h (79.5%vs 39.3%, p < 0.001). The share of false positive ratings was highest for DWI performed within the first 6 h of symptom onset (up to 14.3%). Interrater reliability was "moderate" for DWI performed within the first 18 h (κ = 0.57-0.58), but improved for DWI acquired between 18 and 24 h (κ = 0.94). CONCLUSION DWI-based detection of retinal ischemia in early CRAO is likely to be time-dependent with superior diagnostic accuracy for DWI performed 12-24 h after onset of visual impairment.
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Affiliation(s)
- Kristin Sophie Lange
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Isabelle Mourand
- Department of Neurology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Arthur Coget
- Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Nicolas Menjot de Champfleur
- Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
- I2FH, Institut d’Imagerie Fonctionnelle Humaine, Hôpital Gui de Chauliac, CHRU de Montpellier, Montpellier, France
| | - Xavier Ayrignac
- Department of Neurology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Michael Scheel
- Institute for Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Bohner
- Institute for Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Charlie Zagroun
- Department of Ophthalmology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Eberhard Siebert
- Institute for Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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5
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Boyko M, Dumitrascu O, Saindane AM, Hoxworth JM, Hu R, Rath T, Chan W, Flowers AM, Harahsheh E, Parikh P, Elshaigi O, Meyer BI, Newman NJ, Biousse V. Retinal and optic nerve magnetic resonance diffusion-weighted imaging in acute non-arteritic central retinal artery occlusion. J Stroke Cerebrovasc Dis 2022; 31:106644. [PMID: 35849917 PMCID: PMC9579870 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/25/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES Diffusion weighted imaging hyperintensity (DWI-H) has been described in the retina and optic nerve during acute central retinal artery occlusion (CRAO). We aimed to determine whether DWI-H can be accurately identified on standard brain magnetic resonance imaging (MRI) in non-arteritic CRAO patients at two tertiary academic centers. MATERIALS AND METHODS Retrospective cross-sectional study that included all consecutive adult patients with confirmed acute non-arteritic CRAO and brain MRI performed within 14 days of CRAO. At each center, two neuroradiologists masked to patient clinical data reviewed each MRI for DWI-H in the retina and optic nerve, first independently then together. Statistical analysis for inter-rater reliability and correlation with clinical data was performed. RESULTS We included 204 patients [mean age 67.9±14.6 years; 47.5% females; median time from CRAO to MRI 1 day (IQR 1-4.3); 1.5 T in 127/204 (62.3%) and 3.0 T in 77/204 (37.7%)]. Inter-rater reliability varied between centers (κ = 0.27 vs. κ = 0.65) and was better for retinal DWI-H. Miss and error rates significantly differed between neuroradiologists at each center. After consensus review, DWI-H was identified in 87/204 (42.6%) patients [miss rate 117/204 (57.4%) and error rate 11/87 (12.6%)]. Significantly more patients without DWI-H had good visual acuity at follow-up (p = 0.038). CONCLUSIONS In this real-world case series, differences in agreement and interpretation accuracy among neuroradiologists limited the role of DWI-H in diagnosing acute CRAO on standard MRI. DWI-H was identified in 42.6% of patients and was more accurately detected in the retina than in the optic nerve. Further studies are needed with standardized novel MRI protocols.
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Affiliation(s)
- Matthew Boyko
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA 404-778-5158, United States
| | - Oana Dumitrascu
- Departments of Neurology and Ophthalmology, Mayo Clinic College of Medicine, Scottsdale, AZ 480-301-4151, United States
| | - Amit M Saindane
- Departments of Radiology and Imaging Sciences and Neurological Surgery, Emory University School of Medicine, Atlanta, GA 404-778-2020, United States
| | - Joseph M Hoxworth
- Department of Radiology, Division of Neuroradiology, Mayo Clinic College of Medicine Scottsdale, AZ 480-301-4151, United States
| | - Ranliang Hu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 404-778-2020, United States
| | - Tanya Rath
- Department of Radiology, Division of Neuroradiology, Mayo Clinic College of Medicine Scottsdale, AZ 480-301-4151, United States
| | - Wesley Chan
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA 404-778-5158, United States
| | - Alexis M Flowers
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA 404-778-5158, United States
| | - Ehab Harahsheh
- Department of Neurology, Mayo Clinic College of Medicine Scottsdale, AZ 480-301-4151, United States
| | - Parth Parikh
- Mayo Clinic Alyx School of Medicine, Scottsdale, AZ 480-301-4151, United States
| | - Omer Elshaigi
- Mayo Clinic Alyx School of Medicine, Scottsdale, AZ 480-301-4151, United States
| | - Benjamin I Meyer
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA 404-778-5158, United States
| | - Nancy J Newman
- Departments of Ophthalmology, Neurology and Neurological Surgery, Emory University School of Medicine, Atlanta, GA 404-778-5158, United States
| | - Valérie Biousse
- Departments of Ophthalmology and Neurology, Emory University School of Medicine, Atlanta, GA 404-778-5158, United States.
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