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Zhang J, Guan X, Zhang G, Yin Y, Sha Z, Zhao Y, Li J, Li B, Qiu X. Two cerebral infarctions caused by thrombus and myxomatous embolus in a patient with cardiac myxoma: A case report. Heliyon 2024; 10:e30199. [PMID: 38737257 PMCID: PMC11088245 DOI: 10.1016/j.heliyon.2024.e30199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/14/2024] Open
Abstract
An increasing number of cases of cerebral embolism caused by cardiac myxoma have been reported. However, cerebral infarction caused by different types of emboli obstructing different vascular regions within a short period of time has not been reported. This is the first report to histologically confirm cerebral infarctions independently caused by thrombus and myxomatous embolus in a patient with cardiac myxoma within a period of 23 days. The first cerebral infarction was due to embolization of thrombus to the right middle cerebral artery, whereas the second was due to embolization of tissue from a mucinous tumor to the left middle cerebral artery. Both cerebral infarctions underwent mechanical thrombectomy, but unfortunately, we ultimately failed to save the patient's life. Therefore, further attention should be paid to the surgical resection and treatment of cardiac myxoma.
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Affiliation(s)
- Ju Zhang
- Shandong Second Medical University, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
| | - Xiangfeng Guan
- Shandong Second Medical University, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
| | - Guanzhao Zhang
- Department of Cardiology, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
| | - Yingchun Yin
- Department of Pathology, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
| | - Zuowei Sha
- Department of Pathology, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
| | - Yunhe Zhao
- Department of Cardiology, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
| | - Jing Li
- Department of Pathology, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
| | - Bo Li
- Department of Cardiology, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
| | - Xueliang Qiu
- Department of Neurology, Zibo Central Hospital, NO.10, South Shanghai Road, Zibo, PR China
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Charan BD, Gaikwad SB, Jain S, Garg A, Sebastian LJD, Srivastava MVP, Bhatia R, Pandit AK, Kale SS. An Institutional Perspective on the Number of Stent Retriever Pass and Rate of Recanalization in Mechanical Thrombectomy for Acute Ischemic Stroke: When to Stop? Acta Med Litu 2024; 31:75-80. [PMID: 38978857 PMCID: PMC11227687 DOI: 10.15388/amed.2024.31.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 07/10/2024] Open
Abstract
Background and purpose Mechanical thrombectomy is the standard treatment modality for flow restoration in acute ischemic stroke. In cases of persistent occlusion, the optimal number of retrieval attempts before considering procedure termination is currently undetermined and is a topic for research. Therefore in this study, we studied the impact of the number of stent retrieval maneuvers on the recanalization of vessels. Methods In this retrospective single-center observational study we included 52 patients with large vessel occlusion who underwent stent retriever mechanical thrombectomy. Successful recanalization rate was defined as modified TICI (Thrombolysis in Cerebral Infarction) 2b or 3. Result The overall successful recanalization rate was 44.24%. The recanalization rate per stent retrieval attempt was the highest in 1st attempt (28.84%) and no recanalization was observed with the 3rd, 5th, and 6th attempts (p<0.001). At most 6 retrieval attempts were used. Conclusions After two retrieval attempts, 91% of the patients were successfully recanalized and other after the 5th attempt could not result in recanalization.
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Affiliation(s)
- Bheru Dan Charan
- Department of Neuroimaging & Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shailesh B Gaikwad
- Department of Neuroimaging & Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Savyasachi Jain
- Department of Neuroimaging & Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroimaging & Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | | | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Awadh Kishore Pandit
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Kalinin MN, Khasanova DR. Heterogeneous treatment effects of Cerebrolysin as an early add-on to reperfusion therapy: post hoc analysis of the CEREHETIS trial. Front Pharmacol 2024; 14:1288718. [PMID: 38249342 PMCID: PMC10796496 DOI: 10.3389/fphar.2023.1288718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Background: There has been intensive research into enhancing the effects of reperfusion therapy to mitigate hemorrhagic transformation (HT) in stroke patients. Using neuroprotective agents alongside intravenous thrombolysis (IVT) appears a promising approach. Cerebrolysin is one of the candidates since it consists of neuropeptides mimicking the action of neurotrophic factors on brain protection and repair. Objectives: We looked at treatment effects of Cerebrolysin as an early add-on to IVT in stroke patients with varying HT risk. Methods: It was post hoc analysis of the CEREHETIS trial (ISRCTN87656744). Patients with middle cerebral artery infarction (n = 238) were selected from the intention-to-treat population. To stratify participants according to their HT risk, the DRAGON, SEDAN and HTI scores were computed for each eligible subject using on-admission data. The study endpoints were any and symptomatic HT, and functional outcome measured with the modified Rankin Scale (mRS) on day 90. Favorable functional outcome (FFO) was defined as an mRS ≤2. The performance of each stratification tool was estimated with regression approaches. Heterogeneous treatment effect analysis was conducted using techniques of meta-analysis and the matching-smoothing method. Results: The HTI score outperformed other tools in terms of HT risk stratification. Heterogeneity of Cerebrolysin treatment effects was moderate (I2, 35.8%-56.7%; H2, 1.56-2.31) and mild (I2, 10.9%; H2, 1.12) for symptomatic and any HT, respectively. A significant positive impact of Cerebrolysin on HT and functional outcome was observed in the moderate (HTI = 1) and high (HTI ≥2) HT risk patients, but it was neutral in those with the low (HTI = 0) risk. In particular, there was a steady decline in the rate of symptomatic (HTI = 0 vs. HTI = 4: by 4.3%, p = 0.077 vs. 21.1%, p < 0.001) and any HT (HTI = 0 vs. HTI = 4: by 1.2%, p = 0.737 vs. 32.7%, p < 0.001). Likewise, an mRS score reduction (HTI = 0 vs. HTI = 4: by 1.8%, p = 0.903 vs. 126%, p < 0.001) with a reciprocal increase of the fraction of FFO patients (HTI = 0 vs. HTI = 4: by 1.2% p = 0.757 vs. 35.5%, p < 0.001) was found. Conclusion: Clinically meaningful heterogeneity of Cerebrolysin treatment effects on HT and functional outcome was established in stroke patients. The beneficial effects were significant in those whose estimated on-admission HT risk was either moderate or high.
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Affiliation(s)
- Mikhail N. Kalinin
- Department of Neurology, Kazan State Medical University, Kazan, Russia
- Department of Neurology, Interregional Clinical Diagnostic Center, Kazan, Russia
| | - Dina R. Khasanova
- Department of Neurology, Kazan State Medical University, Kazan, Russia
- Department of Neurology, Interregional Clinical Diagnostic Center, Kazan, Russia
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Kobeissi H, Adusumilli G, Ghozy S, Dmytriw AA, Senol YC, Orscelik A, Bilgin C, Kadirvel R, Brinjikji W, Kallmes DF. First-pass effect in posterior acute ischemic stroke undergoing endovascular thrombectomy: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107304. [PMID: 37579638 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107304] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023] Open
Abstract
OBJECTIVES First-pass effect (FPE) has been shown to be a predictor of favorable clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Literature regarding FPE for posterior circulation AIS is sparse; we conducted a systematic review and meta-analysis to explore FPE in posterior circulation stroke undergoing EVT. MATERIALS AND METHODS We conducted a systematic review of the English literature in PubMed, Embase, Scopus, and Web of Science. FPE was defined as thrombolysis in cerebral infarction (TICI) 2c-3 and modified FPE (mFPE) was defined as TICI 2b-3 in one pass. Definitions of non-FPE and non-mFPE varied among studies. The primary outcome of interest was modified Rankin Scale (mRS) 0-2. Secondary outcomes of interest were mRS 0-3, symptomatic intracranial hemorrhage (sICH), and mortality. We calculated odds ratios (OR) and corresponding 95% confidence intervals (CI). Heterogeneity was assessed with Q statistic and I2 test. RESULTS Seven studies with 417 patients in the mFPE group, 942 in the non-mFPE group, 545 in the FPE group, and 1023 in the non-FPE group were included. Overall, FPE was associated with greater rates of 90-day mRS 0-2 (OR= 2.78, 95% CI= 2.11-3.65; P-value< 0.001) and mRS 0-3 (OR= 2.67, 95% CI= 1.98-3.60; P-value< 0.001); however, there was significant heterogeneity among studies for both mRS 0-2 (I2= 69%; P-value< 0.001) and mRS 0-3 (I2= 69%; P-value< 0.001). FPE and non-FPE were associated with similar rates of sICH (OR= 0.65, 95% CI= 0.40-1.07; P-value= 0.09), and no heterogeneity was observed (I2= 0%; P-value= 0.95). FPE was associated with lower rates of mortality (OR= 0.44, 95% CI= 0.33-0.58; P-value< 0.001), although heterogeneity was observed (I2= 58%; P-value= 0.01). CONCLUSIONS FPE is associated with favorable clinical outcomes in patients undergoing EVT for posterior circulation AIS. Future studies should work to further quantify the impact of FPE on outcomes in the posterior circulation.
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Affiliation(s)
- Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; College of Medicine, Central Michigan University, Mount Pleasant, MI, USA.
| | - Gautam Adusumilli
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Geraldini F, Diana P, Fregolent D, De Cassai A, Boscolo A, Pettenuzzo T, Sella N, Lupelli I, Navalesi P, Munari M. General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis. Can J Anaesth 2023; 70:1167-1181. [PMID: 37268801 DOI: 10.1007/s12630-023-02481-8] [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: 06/16/2022] [Revised: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 06/04/2023] Open
Abstract
PURPOSE Endovascular treatment for stroke patients usually requires anesthesia care, with no current consensus on the best anesthetic management strategy. Several randomized controlled trials and meta-analyses have attempted to address this. In 2022, additional evidence from three new trials was published: the GASS trial, the CANVAS II trial, and preliminary results from the AMETIS trial, prompting the execution of this updated systematic review and meta-analysis. The primary objective of this study was to evaluate the effects of general anesthesia and conscious sedation on functional outcomes measured with the modified Rankin scale (mRS) at three months. METHODS We performed a systematic review and meta-analysis of randomized controlled trials investigating conscious sedation and general anesthesia in endovascular treatment. The following databases were examined: PubMed, Scopus, Embase, and the Cochrane Database of Randomized Controlled Trials and Systematic Reviews. The Risk of Bias 2 tool was used to assess bias. In addition, trial sequence analysis was performed on the primary outcome to estimate if the cumulative effect is significant enough to be unaffected by further studies. RESULTS Nine randomized controlled trials were identified, including 1,342 patients undergoing endovascular treatment for stroke. No significant differences were detected between general anesthesia and conscious sedation with regards to mRS, functional independence (mRS, 0-2), procedure duration, onset to reperfusion, mortality, hospital length of stay, and intensive care unit length of stay. Patients treated under general anesthesia may have more frequent successful reperfusion, though the time from groin to reperfusion was slightly longer. Trial sequential analysis showed that additional trials are unlikely to show marked differences in mean mRS at three months. CONCLUSIONS In this updated systematic review and meta-analysis, the choice of anesthetic strategy for endovascular treatment of stroke patients did not significantly impact functional outcome as measured with the mRS at three months. Patients managed with general anesthesia may have more frequent successful reperfusion. TRIAL REGISTRATION PROSPERO (CRD42022319368); registered 19 April 2022.
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Affiliation(s)
- Federico Geraldini
- UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | - Paolo Diana
- UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | | | - Alessandro De Cassai
- UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | - Annalisa Boscolo
- UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | - Tommaso Pettenuzzo
- UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | - Nicolò Sella
- UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
| | - Irene Lupelli
- Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Navalesi
- UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
- Department of Medicine, University of Padua, Padua, Italy
| | - Marina Munari
- UOC Anesthesia and Intensive Care Unit, Institute of Anesthesia and Intensive Care, Padua University Hospital, Via Giustiniani 1, 35127, Padua, Italy
- Neurointensive Care Unit, Padua University Hospital, Padua, Italy
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Kobeissi H, Ghozy S, Adusumilli G, Bilgin C, Tolba H, Amoukhteh M, Kadirvel R, Brinjikji W, Heit JJ, Rabinstein AA, Kallmes DF. CT Perfusion vs Noncontrast CT for Late Window Stroke Thrombectomy: A Systematic Review and Meta-analysis. Neurology 2023; 100:e2304-e2311. [PMID: 36990720 PMCID: PMC10259276 DOI: 10.1212/wnl.0000000000207262] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/21/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) in the late window (6-24 hours) can be evaluated with CT perfusion (CTP) or with noncontrast CT (NCCT) only. Whether outcomes differ depending on the type of imaging selection is unknown. We conducted a systematic review and meta-analysis comparing outcomes between CTP and NCCT for EVT selection in the late therapeutic window. METHODS This study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guidelines. A systematic literature review of the English language literature was conducted using Web of Science, Embase, Scopus, and PubMed databases. Studies focusing on late-window AIS undergoing EVT imaged through CTP and NCCT were included. Data were pooled using a random-effects model. The primary outcome of interest was rate of functional independence, defined as modified Rankin scale 0-2. The secondary outcomes of interest included rates of successful reperfusion, defined as thrombolysis in cerebral infarction 2b-3, mortality, and symptomatic intracranial hemorrhage (sICH). RESULTS Five studies with 3,384 patients were included in our analysis. There were comparable rates of functional independence (odds ratio [OR] 1.03, 95% CI 0.87-1.22; p = 0.71) and sICH (OR 1.09, 95% CI 0.58-2.04; p = 0.80) between the 2 groups. Patients imaged with CTP had higher rates of successful reperfusion (OR 1.31, 95% CI 1.05-1.64; p = 0.015) and lower rates of mortality (OR 0.79, 95% CI 0.65-0.96; p = 0.017). DISCUSSION Although recovery of functional independence after late-window EVT was not more common in patients selected by CTP when compared with patients selected by NCCT only, patients selected by CTP had lower mortality.
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Affiliation(s)
- Hassan Kobeissi
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN.
| | - Sherief Ghozy
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Gautam Adusumilli
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Cem Bilgin
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Hatem Tolba
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Melika Amoukhteh
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Ramanathan Kadirvel
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Waleed Brinjikji
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Jeremy J Heit
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - David F Kallmes
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
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Della Vecchia C, Préau M, Haesebaert J, Viprey M, Rode G, Termoz A, Dima A, Schott AM. Factors associated with post-stroke social participation: A quantitative study based on the ICF framework. Ann Phys Rehabil Med 2022; 66:101686. [PMID: 35779831 DOI: 10.1016/j.rehab.2022.101686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Post-stroke social participation is a major determinant of quality of life and life satisfaction. However, few data relating to participation determinants are available, especially the influence of psychological factors and factors related to the living environment. OBJECTIVES This study investigated determinants of post-stroke social participation within the International Classification of Functioning, Disability and Health framework. METHODS We contacted people with stroke who had been hospitalized in the Rhône County, included in a previous cohort study, were aged ≥18 years and were not institutionalized. The primary outcome was social participation measured with the Stroke Impact Scale (SIS) 2.0. We performed multiple hierarchical linear regressions to test the following predictors: clinical factors (stroke-related variables, limitations in Activities of Daily Living [ADL]/Instrumental ADL), personal factors (sociodemographic factors, coping strategies) and environmental factors (satisfaction with social relationships and living environment). RESULTS Among the 352 participants, 63% were men, and mean age was 68.7(SD 14.5) years. In the last multivariate model, variables associated with higher levels of social participation were the use of the positive thinking coping strategy (B (SD)=1.17(0.52), p = 0.03), higher perceived satisfaction with the living environment (B (SD)=0.17(0.07), p = 0.03) and fewer perceived activity limitations (B (SD)=0.55 (0.06), p < 0.001). Conversely, the seeking social support coping style (B (SD)= -1.98 (0.60), p = 0.001), and a higher number of stroke-related sequelae (B (SD)= -1.93(0.53), p = 0.001) were associated with lower social participation. CONCLUSIONS The identification of potentially modifiable personal and environmental factors that influence social participation provides elements to strengthen existing rehabilitation programs and opens the way for possible psychosocial interventions.
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Affiliation(s)
- Claire Della Vecchia
- Pole of Social Psychology, Inserm U1296 Unit 'Radiation: Defense, Health Environment', Lyon 2 University, Lyon, France.
| | - Marie Préau
- Pole of Social Psychology, Inserm U1296 Unit 'Radiation: Defense, Health Environment', Lyon 2 University, Lyon, France
| | - Julie Haesebaert
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Hospices Civils de Lyon, Pôle Santé Publique, F-69008 Lyon, France
| | - Marie Viprey
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Hospices Civils de Lyon, Pôle Santé Publique, F-69008 Lyon, France
| | - Gilles Rode
- INSERM U1028, CNRS UMR5292, Centre de Recherche en Neurosciences de Lyon (CRNL), Equipe ImpAct, Bron, France; Service de Médecine Physique et Réadaptation, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Saint-Genis-Laval, France
| | - Anne Termoz
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Hospices Civils de Lyon, Pôle Santé Publique, F-69008 Lyon, France
| | - Alexandra Dima
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Anne-Marie Schott
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Hospices Civils de Lyon, Pôle Santé Publique, F-69008 Lyon, France
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Rao J, Tao Z, Bao Q, Xu M, Jiang M, Weng X, Yin B, Li D, Li Y, Cai X, Fu F. Mechanical Thrombectomy for Acute Ischemic Stroke in Patients With Cardiac Myxoma: A Case Series and Pooled Analysis. Front Neurol 2022; 13:877056. [PMID: 35509996 PMCID: PMC9058073 DOI: 10.3389/fneur.2022.877056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/24/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose Acute ischemic stroke (AIS) is a common and life-threatening complication of patients with cardiac myxoma (CM). The role of the mechanical thrombectomy (MT) technique in CM-AIS patients remains unclear, and no guidelines exist for this population. Therefore, we conducted a case series study of MT in CM-AIS patients to investigate its safety and efficacy via a pooled analysis of published literature. Methods Eleven CM-AIS patients who underwent MT between 2016 and 2021 were screened from multicenter stroke databases. Clinical, procedural, and outcome data were obtained from medical records. A systematic review was conducted to identify additional cases from published studies by searching PubMed and China National Knowledge Infrastructure databases. We then performed a pooled analysis of the published cases. Results In the case series study, most patients were male (81.8%), with a median age of 51 years. All patients had CM located in the left atrium. The rate of successful reperfusion using the first-line thrombectomy technique was 100% with stent retriever (SR) and 66.7% with direct aspiration (DA), which resulted in overall successful reperfusion in 94.1% of all occlusions. The retrieved emboli of the five patients who underwent histopathology examination were identified as myxoma components. Hemorrhagic transformation was observed in five (45.5%) patients, of whom one was symptomatic (9.1%). Three-month favorable functional outcomes were achieved in five (45.5%) patients with a 3-month mortality rate of 18.2%. For the literature review, 35 cases with 51 target vessel occlusions were identified and included in the pooled analysis. The rate of successful reperfusion following first-line thrombectomy did not differ between SR (30 patients, 90.9%) and DA (10 patients, 83.3%). The overall successful reperfusion rate was 91.8% of all occlusions. Three-month favorable functional outcomes were achieved in 21 (60.0%) patients, and the mortality rate was 8.6%. Conclusions Our findings suggest that MT is not only an effective technique but also a safe option for CM-AIS patients with large vessel occlusion. MT has several advantages for this population, which include a high recanalization rate, low bleeding risk, and the ability to evaluate the source of emboli and the etiology of stroke.
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Affiliation(s)
- Jie Rao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Neurology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, China
| | - Zi Tao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qiongqiong Bao
- Department of Neurology, Affiliated Yueqing Hospital, Wenzhou Medical University, Wenzhou, China
| | - Mengbei Xu
- Department of Neurology, Ningbo Second Hospital, Ningbo, China
| | - Mingxia Jiang
- Department of Rehabilitation, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiongpeng Weng
- Department of Neurology, Huangyan Hospital, Wenzhou Medical University, Taizhou, China
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dandong Li
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yan Li
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xueli Cai
- Department of Neurology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, China
- Xueli Cai
| | - Fangwang Fu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Fangwang Fu
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9
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Rastogi A, Weissert R, Bhaskar SMM. Leukoaraiosis severity and post-reperfusion outcomes in acute ischaemic stroke: A meta-analysis. Acta Neurol Scand 2022; 145:171-184. [PMID: 34418060 DOI: 10.1111/ane.13519] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Severity of leukoaraiosis may mediate outcomes after reperfusion therapy in acute ischaemic stroke (AIS) patients. However, the level of the association remains poorly understood. We performed a meta-analysis to investigate the impact of leukoaraiosis severity on functional outcome, survival, haemorrhagic complications, and procedural success in AIS patients treated with intravenous thrombolysis and/or endovascular thrombectomy. MATERIALS AND METHODS PubMed, EMBASE and the Cochrane library were searched for studies on leukoaraiosis in AIS receiving reperfusion therapy. A random-effects meta-analysis was conducted for post-reperfusion outcomes in AIS patients with absent-to-mild leukoaraiosis and moderate-to-severe leukoaraiosis. The strength of association between moderate-to-severe leukoaraiosis and poor outcomes was quantified using odds ratios (OR). RESULTS A total of 15 eligible studies involving 6460 patients (1451 with moderate-to-severe leukoaraiosis and 5009 with absent-to-mild leukoaraiosis) were included in the meta-analysis. Moderate-to-severe leukoaraiosis was significantly associated with poor 90-day functional outcome (OR 3.16; 95% confidence interval (CI) 2.69-3.72; p < .0001), 90-day mortality (OR 3.11; 95% CI 2.27-4.26; p < .0001) and increased risk of symptomatic intracerebral haemorrhage (OR 1.69; 95% CI 1.24-2.32; p = .001) after reperfusion therapy. Overall, no significant association of leukoaraiosis severity with haemorrhagic transformation (HT) and angiographic recanalization status were observed. However, subgroup analysis revealed a significant association of WML severity with HT in patients receiving EVT. CONCLUSION Leukoaraiosis is a useful prognostic biomarker in AIS. Patients with moderate-to-severe leukoaraiosis on baseline imaging are likely to have worse clinical and safety outcomes after reperfusion therapy.
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Affiliation(s)
- Aarushi Rastogi
- Neurovascular Imaging Laboratory Clinical Sciences Stream Ingham Institute for Applied Medical Research Sydney Australia
- South Western Sydney Clinical School University of New South Wales (UNSW) Sydney NSW Australia
| | - Robert Weissert
- Department of Neurology Regensburg University Hospital University of Regensburg Regensburg Germany
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory Clinical Sciences Stream Ingham Institute for Applied Medical Research Sydney Australia
- NSW Brain Clot Bank NSW Health Pathology Sydney Australia
- Department of Neurology and Neurophysiology Liverpool Hospital and South Western Sydney Local Health District Sydney Australia
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10
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Raza SA, Rangaraju S. Prognostic Scores for Large Vessel Occlusion Strokes. Neurology 2021; 97:S79-S90. [PMID: 34785607 DOI: 10.1212/wnl.0000000000012797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/23/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW Endovascular thrombectomy (EVT) for large vessel occlusion strokes (LVOS) presents several treatment challenges. We provide a summary of existing tools for patient selection (pre-EVT tools) and for prognostication of long-term outcomes following reperfusion therapy (post-EVT tools). RECENT FINDINGS Recently published randomized trials demonstrated superiority of EVT over medical therapy alone for LVOS. Uniform patient selection paradigms based on demographic, clinical, and radiographic variables are not completely standardized, leading to variability in patient selection for EVT for LVOS. Post-EVT, an accurate assessment of long-term prognosis is critical in the decision-making process. SUMMARY Prognostic scores can serve as useful adjuncts to facilitate clinical decision-making during early management of patients with ischemic stroke, particularly those with LVOS. The acute management of LVOS comprises rapid clinical assessment, triage, and cerebrovascular imaging, followed by evaluation for candidacy for thrombolysis and EVT. Pre-EVT prognostic tools that accurately predict the likelihood of benefit from EVT may guide reliable, efficient, and cost-effective patient selection. Following EVT, severe stroke deficits and subacute poststroke complications that portend a poor prognosis may warrant invasive therapies. Clinical decisions regarding these treatment options involve careful discussions between providers and patient families, and are also based on prognosis provided by the treating clinician. Reliable post-EVT prognostic tools can facilitate this by providing accurate and objective prognostic information. Several prognostic tools have been developed and validated in the literature, some of which may be applicable in the pre-EVT and post-EVT settings, although clinical utility and application varies. Validation in contemporary datasets as well as implementation and impact studies are needed before these scales can be used to guide clinical decisions for individual patients.
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Affiliation(s)
- Syed Ali Raza
- From the Department of Neurology (S.A.R.), Ochsner Louisiana State University Health Sciences Center, Shreveport; and Department of Neurology (S.R.), Emory University, Atlanta GA
| | - Srikant Rangaraju
- From the Department of Neurology (S.A.R.), Ochsner Louisiana State University Health Sciences Center, Shreveport; and Department of Neurology (S.R.), Emory University, Atlanta GA.
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11
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Pressman E, Waqas M, Sands V, Siddiqui A, Snyder K, Davies J, Levy E, Ionita C, Guerrero W, Ren Z, Mokin M. Factors Associated With Decreased Accuracy of Modified Thrombolysis in Cerebral Infarct Scoring Among Neurointerventionalists During Thrombectomy. Stroke 2021; 52:e733-e738. [PMID: 34496615 DOI: 10.1161/strokeaha.120.033372] [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] [Indexed: 11/16/2022]
Abstract
Background and Purpose The modified Thrombolysis in Cerebral Infarct (mTICI) score is used to grade angiographic outcome after endovascular thrombectomy. We sought to identify factors that decrease the accuracy of intraprocedural mTICI. Methods We performed a 2-center retrospective cohort study comparing operator (n=6) mTICI scores to consensus scores from blinded adjudicators. Groups were also assessed by dichotomizing mTICI scores to 0–2a versus 2b–3. Results One hundred thirty endovascular thrombectomy procedures were included. Operators and adjudicators had a pairwise agreement in 96 cases (73.8%). Krippendorff α was 0.712. Multivariate analysis showed endovascular thrombectomy overnight (odds ratio [OR]=3.84 [95% CI, 1.22–12.1]), lacking frontal (OR, 5.66 [95 CI, 1.36–23.6]), or occipital (OR, 7.18 [95 CI, 2.12–24.3]) region reperfusion, and higher operator mTICI scores (OR, 2.16 [95 CI, 1.16–4.01]) were predictive of incorrectly scoring mTICI intraprocedurally. With dichotomized mTICI scores, increasing number of passes was associated with increased risk of operator error (OR, 1.93 [95 CI, 1.22–3.05]). Conclusions In our study, mTICI disagreement between operator and adjudicators was observed in 26.2% of cases. Interventions that took place between 22:30 and 4:00, featured frontal or occipital region nonperfusion, higher operator mTICI scores, and increased number of passes had higher odds of intraprocedural mTICI inaccuracy.
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Affiliation(s)
- Elliot Pressman
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Victoria Sands
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Kenneth Snyder
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Jason Davies
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Elad Levy
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Ciprian Ionita
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Waldo Guerrero
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
| | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
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12
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Goyal M, Kappelhof M, Ospel JM, Bala F. Balloon guide catheters: use, reject, or randomize? Neuroradiology 2021; 63:1179-1183. [PMID: 34100099 DOI: 10.1007/s00234-021-02739-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
Thrombectomy devices played an important role in the success of endovascular treatment trials over the past five years. A balloon guide catheter (BGC) is an adjunctive device used to arrest and reverse flow by inflating the balloon at its tip, which allows for flow reversal in intracranial arteries during retrieval of thrombectomy devices by applying concomitant aspiration through its lumen. Thereby, it can decrease the risk of clot fragmentation and distal embolization. Despite the numerous benchtop and clinical observational studies showing the superiority of BGC to conventional guide catheters in improving reperfusion quality and clinical outcome, its use is still low in clinical practice. The reasons behind this reluctance might be related to technical and cost issues. Therefore, high level evidence data, i.e., a randomized clinical trial, are needed to increase its implementation in thrombectomy procedures. Nonetheless, several obstacles and challenges can prevent the completion of such a trial, and efforts are needed to overcome them. We provide an overview of the current opinions about BGCs in the neurointerventional community and discuss the feasibility and challenges of a possible randomized trial to answer the question "should a BGC be routinely used in endovascular treatment of acute ischemic stroke?"
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
- Department of Diagnostic Imaging, University of Calgary, Calgary, Canada.
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basil, Switzerland
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
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13
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Rastogi A, Weissert R, Bhaskar SMM. Emerging role of white matter lesions in cerebrovascular disease. Eur J Neurosci 2021; 54:5531-5559. [PMID: 34233379 DOI: 10.1111/ejn.15379] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/26/2021] [Accepted: 06/26/2021] [Indexed: 12/12/2022]
Abstract
White matter lesions have been implicated in the setting of stroke, dementia, intracerebral haemorrhage, several other cerebrovascular conditions, migraine, various neuroimmunological diseases like multiple sclerosis, disorders of metabolism, mitochondrial diseases and others. While much is understood vis a vis neuroimmunological conditions, our knowledge of the pathophysiology of these lesions, and their role in, and implications to, management of cerebrovascular diseases or stroke, especially in the elderly, are limited. Several clinical assessment tools are available for delineating white matter lesions in clinical practice. However, their incorporation into clinical decision-making and specifically prognosis and management of patients is suboptimal for use in standards of care. This article sought to provide an overview of the current knowledge and recent advances on pathophysiology, as well as clinical and radiological assessment, of white matter lesions with a focus on its development, progression and clinical implications in cerebrovascular diseases. Key indications for clinical practice and recommendations on future areas of research are also discussed. Finally, a conceptual proposal on putative mechanisms underlying pathogenesis of white matter lesions in cerebrovascular disease has been presented. Understanding of pathophysiology of white matter lesions and how they mediate outcomes is important to develop therapeutic strategies.
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Affiliation(s)
- Aarushi Rastogi
- South Western Sydney Clinical School, University of New South Wales (UNSW), Liverpool, New South Wales, Australia.,Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Robert Weissert
- Department of Neurology, Regensburg University Hospital, University of Regensburg, Regensburg, Germany
| | - Sonu Menachem Maimonides Bhaskar
- South Western Sydney Clinical School, University of New South Wales (UNSW), Liverpool, New South Wales, Australia.,Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,NSW Brain Clot Bank, NSW Health Pathology, Sydney, New South Wales, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital and South Western Sydney Local Health District, Sydney, New South Wales, Australia
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14
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Zotter M, Piechowiak EI, Balasubramaniam R, Von Martial R, Genceviciute K, Blanquet M, Slavova N, Sarikaya H, Arnold M, Gralla J, Jung S, Fischer U, El-Koussy M, Heldner MR. Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis. Ther Adv Neurol Disord 2021; 14:1756286421999017. [PMID: 33786067 PMCID: PMC7958159 DOI: 10.1177/1756286421999017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background and aims: To investigate whether stroke aetiology affects outcome in patients with
acute ischaemic stroke who undergo endovascular therapy. Methods: We retrospectively analysed patients from the Bernese Stroke Centre Registry
(January 2010–September 2018), with acute large vessel occlusion in the
anterior circulation due to cardioembolism or large-artery atherosclerosis,
treated with endovascular therapy (±intravenous thrombolysis). Results: The study included 850 patients (median age 77.4 years, 49.3% female, 80.1%
with cardioembolism). Compared with those with large-artery atherosclerosis,
patients with cardioembolism were older, more often female, and more likely
to have a history of hypercholesterolaemia, atrial fibrillation, current
smoking (each p < 0.0001) and higher median National
Institutes of Health Stroke Scale (NIHSS) scores on admission
(p = 0.030). They were more frequently treated with
stent retrievers (p = 0.007), but the median number of
stent retriever attempts was lower (p = 0.016) and fewer
had permanent stent placements (p ⩽ 0.004). Univariable
analysis showed that patients with cardioembolism had worse 3-month survival
[72.7% versus 84%, odds ratio (OR) = 0.51;
p = 0.004] and modified Rankin scale (mRS) score shift
(p = 0.043) and higher rates of post-interventional
heart failure (33.5% versus 18.5%, OR = 2.22;
p < 0.0001), but better modified thrombolysis in
cerebral infarction (mTICI) score shift (p = 0.025).
Excellent (mRS = 0–1) 3-month outcome, successful reperfusion
(mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson
Comorbidity Index were similar between groups. Propensity-matched analysis
found no statistically significant difference in outcome between stroke
aetiology groups. Stroke aetiology was not an independent predictor of
favourable mRS score shift, but lower admission NIHSS score, younger age and
independence pre-stroke were (each p < 0.0001). Stroke
aetiology was not an independent predictor of heart failure, but older age,
admission antithrombotics and dependence pre-stroke were (each ⩽0.027).
Stroke aetiology was not an independent predictor of favourable mTICI score
shift, but application of stent retriever and no permanent intracranial
stent placement were (each ⩽0.044). Conclusion: We suggest prospective studies to further elucidate differences in
reperfusion and outcome between patients with cardioembolism and
large-artery atherosclerosis.
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Affiliation(s)
- Meredeth Zotter
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Rascha Von Martial
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Kotryna Genceviciute
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Marisa Blanquet
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Nedelina Slavova
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Freiburgstrasse, Bern, 3010, Switzerland
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15
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Flottmann F, Brekenfeld C, Broocks G, Leischner H, McDonough R, Faizy TD, Deb-Chatterji M, Alegiani A, Thomalla G, Mpotsaris A, Nolte CH, Fiehler J, Maros ME. Good Clinical Outcome Decreases With Number of Retrieval Attempts in Stroke Thrombectomy: Beyond the First-Pass Effect. Stroke 2021; 52:482-490. [PMID: 33467875 PMCID: PMC7834657 DOI: 10.1161/strokeaha.120.029830] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. Often, more than one retrieval attempt is needed to achieve reperfusion. We aimed to quantify the influence of endovascular therapy on clinical outcome depending on the number of retrievals needed for successful reperfusion in a large multi-center cohort. Methods: For this observational cohort study, 2611 patients from the prospective German Stroke Registry included between June 2015 and April 2018 were analyzed. Patients who received endovascular therapy for acute anterior circulation stroke with known admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction score, and number of retrievals were included. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. The primary outcome was defined as functional independence (modified Rankin Scale score of 0–2) at day 90. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers and confounders. Results: The inclusion criteria were met by 1225 patients. The odds of good clinical outcome decreased with every retrieval attempt required for successful reperfusion: the first retrieval had the highest odds of good clinical outcome (adjusted odds ratio, 6.45 [95% CI, 4.0–10.4]), followed by the second attempt (adjusted odds ratio, 4.56 [95% CI, 2.7–7.7]), and finally the third (adjusted odds ratio, 3.16 [95% CI, 1.8–5.6]). Conclusions: Successful reperfusion within the first 3 retrieval attempts is associated with improved clinical outcome compared with patients without reperfusion. We conclude that at least 3 retrieval attempts should be performed in endovascular therapy of anterior circulation strokes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03356392.
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Affiliation(s)
- Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Milani Deb-Chatterji
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anna Alegiani
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anastasios Mpotsaris
- University Clinic for Neuroradiology, Otto-von-Guericke-University Magdeburg, Germany (A.M.)
| | - Christian H Nolte
- Department of Neurology (C.H.N.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin (C.H.N.), Charité-Universitätsmedizin Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Máté E Maros
- Department of Neuroradiology (M.E.M.), Heidelberg University, Mannheim, Germany.,Department of Biomedical Informatics at the Center for Preventive Medicine and Digital Health (M.E.M.), Heidelberg University, Mannheim, Germany
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16
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Lin CJ, Saver JL. The Minimal Clinically Important Difference for Achievement of Substantial Reperfusion With Endovascular Thrombectomy Devices in Acute Ischemic Stroke Treatment. Front Neurol 2020; 11:524220. [PMID: 33123069 PMCID: PMC7569750 DOI: 10.3389/fneur.2020.524220] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 08/17/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Recent noninferiority clinical trials of novel endovascular thrombectomy devices for acute ischemic stroke have used substantial reperfusion as the primary outcome of achievement. Determining the minimal clinically important difference (MCID) is an essential step for the design of noninferiority clinical trials. Materials and Methods: We surveyed international neuro-interventionalist and noninterventional vascular neurologist investigators. The questionnaire included demographic characteristics, level of clinical experience, and their MCID clinical scenario-based judgment regarding the MCID for the outcome substantial reperfusion (thrombolysis in cerebral infarction score 2b-3) within 3 passes. Results: Survey responses were received from 58 of 200 experts. Among responders, 75.9% were neuro-interventionalists (most commonly interventional neuroradiologists and interventional neurologists, followed by endovascular neurosurgeons), and 24.1% were noninterventional vascular neurologists; 87.9% had been in practice for more than 5 years, and 67.3% devoted more than half of their practice to stroke care. Responder-nonresponder and continuum of resistance analysis indicated responders were representative of the full expert population. Among experts, the median MCID for substantial reperfusion was 3.1-5% (interquartile range 1.1-3% to 5.1-10%). MCID distributions did not differ among neuro-interventionalists and noninterventional vascular neurologists. Conclusions: Neuro-interventionl and noninterventional stroke experts judged that the minimal clinically important difference in comparing thrombectomy devices for achieving substantial reperfusion is 3.1-5%. This MCID, lower than noninferiority margins used in several recent clinical trials, can inform trial designs and clinical development.
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Affiliation(s)
- Chun-Jen Lin
- Neurological Institute, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jeffrey L Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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17
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Liu S, Liu P, Wang P, Zhang F, Wang L, Wang Y, Lu H, Ma X. Argatroban Increased the Basal Vein Drainage and Improved Outcomes in Acute Paraventricular Ischemic Stroke Patients. Med Sci Monit 2020; 26:e924593. [PMID: 32667287 PMCID: PMC7382300 DOI: 10.12659/msm.924593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Since venous drainage in acute arterial ischemic stroke has not been thoroughly researched, we evaluate the effect of argatroban, a selective direct thrombin inhibitor, as a therapy to increase the rate of basal vein Rosenthal (BVR) drainage and improve patients’ post-stroke outcomes. Material/Methods In this multicenter clinical trial, 60 eligible patients at 4.5 to 48 hours after the stroke onset were recruited. After being randomly allocated into 2 groups, they were treated with standard therapy either alone or with argatroban. Results Compared to the contralateral brain hemisphere, the mean flow velocity (MFV) in BVR drainage was significantly reduced in the stroke-afflicted ipsilateral hemisphere. After treatment with argatroban for 7 days, the MFV from BVR of the ipsilateral hemisphere in the argatroban treated group was significantly increased when compared to the control group. At 90 days after the onset of stroke, the MFV of BVR in the ipsilateral hemisphere was similar in both groups. Compared with controls, the argatroban-treated patients had smaller lesions from baseline to 7 days. Argatroban also improved National Institutes of Health Stroke Scale (NIHSS) scores on day 7 after the onset of stroke. Furthermore, the argatroban group’s neurological functions were superior to those of their untreated counterparts after 90 days. No difference was found in the incidence of adverse reactions between the 2 groups. Conclusions These observations indicate that vein drainage change may contribute to the acute phase of brain edema and the outcomes of ischemic stroke patients. Clinical Trial Registration URL-http://www.chictr.org Unique identifier: ChiCTR-IPR-16008663
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Affiliation(s)
- Shoufeng Liu
- The Graduate School, Tianjin Medical University, Tianjin, China (mainland).,Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China (mainland)
| | - Peipei Liu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China (mainland)
| | - Po Wang
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China (mainland)
| | - Fang Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China (mainland)
| | - Lijun Wang
- Department of Neurology, Tianjin Fourth Central Hospital, Tianjin, China (mainland)
| | - Yu Wang
- Department of Ultrasonography, Tianjin Huanhu Hospital, Tianjin, China (mainland)
| | - Hao Lu
- Department of Radiology, Tianjin Huanhu Hospital, Tianjin, China (mainland)
| | - Xiaofeng Ma
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China (mainland)
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18
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Machine learning volumetry of ischemic brain lesions on CT after thrombectomy—prospective diagnostic accuracy study in ischemic stroke patients. Neuroradiology 2020; 62:1239-1245. [DOI: 10.1007/s00234-020-02419-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
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19
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Kaesmacher J, Bellwald S, Dobrocky T, Meinel TR, Piechowiak EI, Goeldlin M, Kurmann CC, Heldner MR, Jung S, Mordasini P, Arnold M, Mosimann PJ, Schroth G, Mattle HP, Gralla J, Fischer U. Safety and Efficacy of Intra-arterial Urokinase After Failed, Unsuccessful, or Incomplete Mechanical Thrombectomy in Anterior Circulation Large-Vessel Occlusion Stroke. JAMA Neurol 2020; 77:318-326. [PMID: 31816018 PMCID: PMC6902179 DOI: 10.1001/jamaneurol.2019.4192] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/27/2019] [Indexed: 12/29/2022]
Abstract
Importance Achieving complete reperfusion is a key determinant of good outcome in patients treated with mechanical thrombectomy (MT). However, data on treatments geared toward improving reperfusion after incomplete MT are sparse. Objective To determine whether administration of intra-arterial urokinase is safe and improves reperfusion after failed or incomplete MT. Design, Setting, and Participants This observational cohort study included a consecutive sample of patients treated with second-generation MT from January 1, 2010, through August 4, 2017. Data were collected from the prospective registry of a tertiary care stroke center. Of 1274 patients screened, 69 refused to participate, and 993 met the observational studies inclusion criteria of a large vessel occlusion in the anterior circulation. Data were analyzed from September 1, 2017, through September 20, 2019. Intervention One hundred patients received intra-arterial urokinase after failed or incomplete MT using manual microcatheter injections. Main Outcomes and Measures Primary safety outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the Prolyse in Acute Cerebral Thromboembolism II criteria. Secondary end points included 90-day mortality and 90-day functional independence (defined as modified Rankin Scale score of ≤2). Efficacy was evaluated angiographically, applying the Thrombolysis in Cerebral Infarction (TICI) scale. Results After exclusion of patients with posterior circulation strokes and those treated with intra-arterial thrombolytics only, 993 patients were included in the final analyses (median age, 74.6 [interquartile range, 62.6-82.2] years; 505 [50.9%] women). Additional intra-arterial urokinase was administered in 100 patients (10.1%). The most common reason for administering intra-arterial urokinase was incomplete reperfusion (TICI<3) after MT (53 [53.0%]). After adjusting for baseline characteristics underlying case selection, intra-arterial urokinase was not associated with an increased risk of sICH (adjusted odds ratio [aOR], 0.81; 95% CI, 0.31-2.13) or 90-day mortality (aOR, 0.78; 95% CI, 0.43-1.40). Among 53 cases of partial or near-complete reperfusion and treated with intra-arterial urokinase, 32 (60.4%) had early reperfusion improvement, and 18 of 53 (34.0%) had an improvement in TICI grade. Correspondingly, patients treated with intra-arterial urokinase had higher rates of functional independence after adjusting for the selection bias favoring a priori poor TICI grades in the intra-arterial urokinase group (aOR, 1.93; 95% CI, 1.11-3.37). Conclusions and Relevance In selected patients, adjunctive treatment with intra-arterial urokinase during or after MT was safe and improved angiographic reperfusion. Systemic evaluation of this approach in a multicenter prospective registry or a randomized clinical trial seems warranted.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- University Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Sebastian Bellwald
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Martina Goeldlin
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph C. Kurmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pascal J. Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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20
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Meinel TR, Kaesmacher J, Mordasini P, Mosimann PJ, Jung S, Arnold M, Heldner MR, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Pereira VM, Gralla J, Fischer U. Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry. Ther Adv Neurol Disord 2019; 12:1756286419835708. [PMID: 30944585 PMCID: PMC6437320 DOI: 10.1177/1756286419835708] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/03/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE In acute ischaemic stroke (AIS) of the anterior circulation (AC) treated with mechanical thrombectomy (MT), data point to a decline of treatment effect with increasing time from symptom onset to treatment. However, the magnitude of the decline will depend on the clinical setting and imaging selection used. The aims of this study were (1) to evaluate the clinical effect of time to reperfusion (TTR); and (2) to assess the safety and technical efficacy of MT according to strata of TTR. METHODS Using the retrospective multicentre BEYOND-SWIFT registry data (ClinicalTrials.gov identifier: NCT03496064), we compared safety and efficacy of MT in 1461 patients between TTR strata of 0-180 min (n = 192), 180-360 min (n = 876) and >360 min (n = 393). Clinical effect of TTR was evaluated using multivariable logistic regression analyses adjusting for pre-specified confounders [adjusted odds ratios (aOR) and 95% confidence intervals (95% CI)]. Primary outcome was good functional outcome (modified Rankin Scale: mRS 0-2) at day 90. RESULTS Every hour delay in TTR was a significant factor related to mRS 0-2 (aOR 0.933, 95% CI 0.887-0.981) with an estimated 1.5% decreased probability of good functional outcome per hour delay of reperfusion, and mRS 0-1 (aOR 0.929, 95% CI 0.877-0.985). Patients with late TTR had lower rates of successful and excellent reperfusion, higher complication rates and number of passes. CONCLUSIONS TTR is an independent factor related to long-term functional outcome. With increasing TTR, interventional procedures become technically less effective. Efforts should be made to shorten TTR through optimized prehospital and in-hospital pathways.
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Affiliation(s)
- Thomas Raphael Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pascal J. Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam Rachel Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Lausanne, Switzerland
| | - Steven D. Hajdu
- Department of Radiology, CHUV Lausanne, Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Laurent Pierot
- Department of Neurology, Toronto Western Hospital, Toronto, Canada
| | | | - Joanna Schaafsma
- Department of Neurology, Toronto Western Hospital, Toronto, Canada
| | | | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, CH-3010, Switzerland
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21
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Clinical Efficacy and Therapeutic Mechanisms of Traditional Chinese Medicine for Neuroprotection and Neurogenesis in Stroke Treatment. DIGITAL CHINESE MEDICINE 2018. [DOI: 10.1016/s2589-3777(19)30026-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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22
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Manning NW, Wenderoth J, Alsahli K, Cordato D, Cappelen-Smith C, McDougall A, Zagami AS, Cheung A. Endovascular Thrombectomy >24-hr From Stroke Symptom Onset. Front Neurol 2018; 9:501. [PMID: 30026722 PMCID: PMC6041982 DOI: 10.3389/fneur.2018.00501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/08/2018] [Indexed: 12/24/2022] Open
Abstract
Background: Trials have demonstrated efficacy for endovascular thrombectomy (EVT) for anterior circulation acute ischaemic stroke (AIS) up to 24-h from symptom onset. The magnitude of effect suggests benefit may exist beyond 24-h. Objectives: To perform a retrospective review of all patients undergoing EVT for anterior circulation LVO stroke beyond 24-h from symptom onset and assess safety and efficacy. Methods:A prospectively maintained database of EVT patients treated at two comprehensive stroke centers between January 2016 and December 2017 was retrospectively screened. Patients undergoing EVT for anterior circulation AIS >24-h from symptom onset were selected. Results: A total of 429 AIS patient underwent EVT in the study period. Five patients treated >24-h from symptom onset were identified. The median age was 72 (range 42–84); median ASPECTS 8 (range 6–8); median baseline-NIHSS 9 (range 4–17); and median time from symptom onset to groin puncture 44 h and 55 min (range 25:07-90:10). One patient underwent CT perfusion imaging. The remaining four patients were selected based on non-contrast CT brain and CT-angiography. Two patients had tandem cervical carotid lesions and underwent acute stenting. Modified thrombolysis in cerebral ischaemia (mTICI) 3 reperfusion was achieved in four patients. No hemorrhagic transformation occurred. All patients were alive at 90-day follow-up. Four patients achieved functional independence at 90-days (mRS 0-2). Conclusion: Endovascular thrombectomy for AIS patients beyond 24-h from symptom onset appears to be safe and effective in this limited study. There is a need for further evidence-based trials of benefit vs. risk in very prolonged time windows.
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Affiliation(s)
- Nathan W Manning
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.,Florey Institute of Neuroscience, Parkville, VIC, Australia
| | - Jason Wenderoth
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Khalid Alsahli
- Department of Radiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Dennis Cordato
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Cecilia Cappelen-Smith
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Alan McDougall
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Alessandro S Zagami
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
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