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Liu HY, Heit JJ, Yuen N, Yang CH, Mlynash M, Zamarud A, Lun R, Lansberg MG, Albers GW. Clinical and Perfusion Imaging Characteristics of Acute Large Vessel Occlusion in Intracranial Atherosclerosis: Clinical and Perfusion Imaging in ICAD-LVO. J Stroke Cerebrovasc Dis 2024:108024. [PMID: 39303867 DOI: 10.1016/j.jstrokecerebrovasdis.2024.108024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 09/03/2024] [Accepted: 09/17/2024] [Indexed: 09/22/2024] Open
Abstract
OBJECTIVES This study aimed to compare clinical and perfusion imaging profiles in acute ischemic stroke with large vessel occlusion (AIS-LVO) between patients with intracranial atherosclerotic disease (ICAD) and non-ICAD who underwent endovascular treatment (EVT). METHODS Data from AIS-LVO patients over the anterior circulation undergoing EVT across two stroke centers were retrospectively analyzed. Clinical profiles and perfusion parameters from automated processing of perfusion imaging were compared between ICAD and non-ICAD groups. Ischemic core was defined as relative cerebral blood flow < 30% on CT perfusion or apparent diffusion coefficient ≤ 620 × 10-6 mm2/s on MR diffusion weighted imaging. RESULTS A total of 111 patients were included (46 ICAD, 65 non-ICAD). The ICAD group exhibited a higher male proportion (60.9% vs. 35.4%), more M1 segment occlusions (78.3% vs. 56.9%), lower atrial fibrillation rates (17.4% vs. 63.1%), and lower baseline NIH Stroke Scale (NIHSS) scores (median [IQR]: 13 [8.75-18] vs. 15 [10-21]) at presentation compared to non-ICAD (all p< 0.05). However, there was no difference in NIHSS scores at discharge or in good functional outcomes (modified Rankin Scale 0-2) at 3 months between the two groups. ICAD patients also had smaller median ischemic core volumes (0 [IQR 0-9.7] vs. 4.4 [0-21.6] ml, p=0.038), smaller median Tmax >6s tissue volulmes (89.3 [IQR 51.1-147.1] vs. 124.4 [80.5-178.6] ml, p=0.017) and lower median HIR (hypoperfusion intensity ratio defined as Tmax >10s divided by Tmax >6s; 0.28 [IQR 0.09-0.42] vs. 0.44 [0.24-0.60], p=0.003). Higher baseline NIHSS scores correlated with larger Tmax >6s lesion volumes as well as higher HIR value in non-ICAD patients, but not in ICAD patients. CONCLUSIONS In anterior circulation of AIS-LVO, ICAD patients exhibited distinct clinical presentations and perfusion imaging characteristics when compared to non-ICAD patients. Perfusion imaging profiles may serve as indicators for identifying ICAD patients before EVT.
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Affiliation(s)
- Hung-Yu Liu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Nicole Yuen
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Chung-Han Yang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Michael Mlynash
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Aroosa Zamarud
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Ronda Lun
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California, USA.
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Zhou X, Lu Y, Lin Y, Lin W, Deng J, Liu X. Association between blood pressure variability and clinical outcomes after successful thrombectomy in acute basilar artery occlusion stroke patients: A multicenter cohort study. J Stroke Cerebrovasc Dis 2024; 33:107893. [PMID: 39179189 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 05/30/2024] [Accepted: 07/25/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Limited data are available on the appropriate choice of blood pressure management strategy for patients with acute basilar artery occlusion (BAO) treated with mechanical thrombectomy (MT). We evaluated the impact of blood pressure variability on clinical outcomes after MT in patients with acute BAO. METHODS This multicenter cohort study included 108 patients with acute BAO who underwent successful emergency thrombectomy at two comprehensive stroke centers from 2016 to 2021. Blood pressure was measured hourly during the first 24 h after successful reperfusion. Blood pressure variability was calculated as mean arterial pressure (MAP) assessed by the standard deviation (SD). Multivariate logistic models were used to investigate the association between BPV, the primary outcome (futile recanalization, 90-day modified Rankin Scale score 3-6), and the secondary outcome (30-day mortality). Subgroup analysis was performed as a sensitivity test. RESULTS Futile recanalization occurred in 60 (56 %) patients, while 26 (24 %) patients died within 30 days. In the fully adjusted model, MAP SD was associated with a higher risk of futile recanalization (OR adj=1.36, per 1 mmHg increase, 95 % CI: 1.09-1.69, P=0.006) and 30-day mortality (OR adj=1.56, per 1 mmHg increase, 95 % CI: 1.20-2.04, P=0.001). A significant interaction between MAP SD and the lack of hypertension history on futile recanalization (P<0.05) was observed. CONCLUSIONS Among recanalized acute BAO ischemic patients, higher blood pressure variability during the first 24 h after MT was associated with worse outcomes. This association was stronger in patients without a history of hypertension.
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Affiliation(s)
- Xiaoyu Zhou
- Department of Neurology, Shanghai Tenth People's Hospital, School of clinical medicine of Nanjing Medical University, No 301, Yanchang Middle Road, Shanghai 200072, China
| | - You Lu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yingying Lin
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenjian Lin
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiangshan Deng
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xueyuan Liu
- Department of Neurology, Shanghai Tenth People's Hospital, School of clinical medicine of Nanjing Medical University, No 301, Yanchang Middle Road, Shanghai 200072, China.
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Uchida K, Yamagami H, Sakai N, Shirakawa M, Beppu M, Toyoda K, Matsumaru Y, Matsumoto Y, Todo K, Hayakawa M, Shindo S, Ota S, Morimoto M, Takeuchi M, Imamura H, Ikeda H, Tanaka K, Ishihara H, Kakita H, Sano T, Araki H, Nomura T, Sakakibara F, Yoshimura S. Endovascular therapy for acute intracranial large vessel occlusion due to atherothrombosis: Multicenter historical registry. J Neurointerv Surg 2024; 16:884-891. [PMID: 37648433 DOI: 10.1136/jnis-2023-020670] [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: 06/06/2023] [Accepted: 08/04/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Atherothrombotic stroke-related large vessel occlusion (AT-LVO) is caused by two etiologies, the intracranial artery occlusion due to in situ occlusion (intracranial group) or due to embolism from cervical carotid occlusion or stenosis (tandem group). The prognosis and reocclusion rate of each etiology after endovascular therapy (EVT) is unclear. METHODS We conducted a historical multicenter registry study at 51 Japanese centers to compare the prognoses of AT-LVO between two etiologies. The primary outcome was the incidence of recurrent ischemic stroke or reocclusion of the treated vessels within 90 days after EVT. Each of the primary outcome means the incidence of recurrent ischemic stroke and reocclusion of the treated vessels within 90 days after EVT. RESULTS We analyzed 582 patients (338 in the intracranial group and 244 in the tandem group). Patients in the intracranial group were younger (mean 71.9 vs 74.5, p=0.003), more of them were female and fewer of them were current smokers than those in the tandem group. In the tandem group, the patients' National Institutes of Health Stroke Scale score on admission was higher (13 vs 15, p=0.006), onset to puncture time was shorter (299 [145-631] vs 232 [144-459] minutes, p=0.03) and Alberta Stroke Program Early CT Score (ASPECTS) was lower (8 [7-9] vs 8 [6-9], p=0.0002). The primary outcome was higher in the intracranial group (22.5% vs 8.2%, p<0.0001). However, any ICH and death were not significantly different in the two groups. CONCLUSIONS The incidence of recurrent ischemic stroke or reocclusion after EVT for AT-LVO was higher in the intracranial group.
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Affiliation(s)
- Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Nobuyuki Sakai
- Neurovascular Research & Neuroendovascular Therapy, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Mikiya Beppu
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasushi Matsumoto
- Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Sendai, Japan
| | - Kenichi Todo
- Stroke Center, Osaka University Graduate School of Medicine, Suita, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Seigo Shindo
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
- Department of Neurology, Kumamoto University, Kumamoto, Japan
| | - Shinzo Ota
- Department of Neurosurgery, Brain Attack Center Ota Memorial Hospital, Fukuyama, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | | | - Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
| | - Hiroto Kakita
- Department of Neurosurgery, Shimizu Hospital, Kyoto, Japan
| | - Takanori Sano
- Department of Neurosurgery, Japanese Red Cross Ise Hospital, Ise, Japan
| | - Hayato Araki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan
| | - Tatsufumi Nomura
- Neuroendovasucular Therapy Center, Ohkawara Neurosurgical Hospital, Muroran, Japan
| | | | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
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Rodriguez-Calienes A, Siddiqui FM, Galecio-Castillo M, Mohammaden MH, Dolia JN, Grossberg JA, Pabaney A, Hassan AE, Tekle WG, Saei H, Miller S, Majidi S, T Fifi J, Valestin G, Siegler JE, Penckofer M, Zhang L, Sheth SA, Salazar-Marioni S, Iyyangar A, Nguyen TN, Abdalkader M, Linfante I, Dabus G, Mehta BP, Sessa J, Jumma MA, Sugg RM, Linares G, Nogueira RG, Liebeskind DS, Haussen DC, Ortega-Gutierrez S. Rescue Therapy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Pooled Analysis of the Society of Vascular and Interventional Neurology Registry. Ann Neurol 2024; 96:343-355. [PMID: 38752428 DOI: 10.1002/ana.26967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT). METHODS This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009). INTERPRETATION Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Neuroscience, Clinical Effectiveness, and Public Health Research Group, Universidad Cientifica del Sur, Lima, Peru
| | - Fazeel M Siddiqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Mahmoud H Mohammaden
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jaydevsinh N Dolia
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Wondwossen G Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Hamzah Saei
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Samantha Miller
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Shahram Majidi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johana T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabrielle Valestin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Mary Penckofer
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Linda Zhang
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Sunil A Sheth
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Sergio Salazar-Marioni
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Ananya Iyyangar
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Italo Linfante
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | | | - Joy Sessa
- Memorial Neuroscience Institute, Pembroke Pines, FL, USA
| | | | - Rebecca M Sugg
- University of South Alabama Medical Center, Mobile, AL, USA
| | | | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Diogo C Haussen
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Gao F, Tong X, Jia B, Wei M, Pan Y, Yang M, Sun D, Nguyen TN, Ren Z, Demiraj F, Yao X, Xu C, Yuan G, Wan Y, Tang J, Wang J, Jiang Y, Wang C, Luo X, Yang H, Shen R, Wu Z, Yuan Z, Wan D, Hu W, Liu Y, Jing P, Wei L, Zheng T, Wu Y, Yang X, Sun Y, Wen C, Chang M, Yin B, Li D, Duan J, Sun D, Guo Z, Xu G, Wang G, Wang L, Wang Y, Jia W, Ma G, Huo X, Mo D, Ma N, Liu L, Zhao X, Wang Y, Fiehler J, Wang Y, Miao Z. Bailout intracranial angioplasty or stenting following thrombectomy for acute large vessel occlusion in China (ANGEL-REBOOT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet Neurol 2024; 23:797-806. [PMID: 38914085 DOI: 10.1016/s1474-4422(24)00186-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Unsuccessful recanalisation or reocclusion after thrombectomy is associated with poor outcomes in patients with large vessel occlusion (LVO) acute ischaemic stroke (LVO-AIS). Bailout angioplasty or stenting (BAOS) could represent a promising treatment for these patients. We conducted a randomised controlled trial with the aim to investigate the safety and efficacy of BAOS following thrombectomy in patients with LVO. METHODS ANGEL-REBOOT was an investigator-initiated, multicentre, prospective, randomised, controlled, open-label, blinded-endpoint clinical trial conducted at 36 tertiary hospitals in 19 provinces in China. Participants with LVO-AIS 24 h after symptom onset were eligible if they had unsuccessful recanalisation (expanded Thrombolysis In Cerebral Infarction score of 0-2a) or risk of reocclusion (residual stenosis >70%) after thrombectomy. Eligible patients were randomly assigned by the minimisation method in a 1:1 ratio to undergo BAOS as the intervention treatment, or to receive standard therapy (continue or terminate the thrombectomy procedure) as a control group, both open-label. In both treatment groups, tirofiban could be recommended for use during and after the procedure. The primary outcome was the change in modified Rankin Scale score at 90 days, assessed in the intention-to-treat population. Safety outcomes were compared between groups. This trial was completed and registered at ClinicalTrials.gov (NCT05122286). FINDINGS From Dec 19, 2021, to March 17, 2023, 706 patients were screened, and 348 were enrolled, with 176 assigned to the intervention group and 172 to the control group. No patients withdrew from the trial or were lost to follow-up for the primary outcome. The median age of patients was 63 years (IQR 55-69), 258 patients (74%) were male, and 90 patients (26%) were female; all participants were Chinese. After random allocation, tirofiban was administered either intra-arterially, intravenously, or both in 334 [96%] of 348 participants. No between-group differences were observed in the primary outcome (common odds ratio 0·86 [95% CI 0·59-1·24], p=0·41). Mortality was similar between the two groups (19 [11%] of 176 vs 17 [10%] of 172), but the intervention group showed a higher risk of symptomatic intracranial haemorrhage (eight [5%] of 175 vs one [1%] of 169), parenchymal haemorrhage type 2 (six [3%] of 175 vs none in the control group), and procedure-related arterial dissection (24 [14%] of 176 vs five [3%] of 172). INTERPRETATION Among Chinese patients with unsuccessful recanalisation or who are at risk of reocclusion after thrombectomy, BAOS did not improve clinical outcome at 90 days, and incurred more complications compared with standard therapy. The off-label use of tirofiban might have affected our results and their generalisability, but our findings do not support the addition of BAOS for such patients with LVO-AIS. FUNDING Beijing Natural Science Foundation, National Natural Science Foundation of China, National Key R&D Program Beijing Municipal Administration of Hospitals Incubating Program, Shanghai HeartCare Medical Technology, HeMo (China) Bioengineering, Sino Medical Sciences Technology.
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Affiliation(s)
- Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Wei
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ming Yang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA; Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Zeguang Ren
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Francis Demiraj
- Department of Neurology, Florida Atlantic University Schmidt College of Medicine, Boca Raton, FL, USA
| | - Xiaoxi Yao
- Department of Neurology, The First People's Hospital of Chenzhou, Chenzhou, China
| | - Chenghua Xu
- Department of Neurology, The First People's Hospital of Taizhou, Taizhou, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Yue Wan
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Jianjun Tang
- Department of Neurology, Shanghai Neuromedical Center, Shanghai, China
| | - Jing Wang
- Department of Neurointerventional Radiology, Beijing Fengtai You'anmen Hospital, Beijing, China
| | - Yuanfei Jiang
- Department of Neurology, Tai'an Hospital of Chinese Medicine, Tai'an, China
| | - Chaobin Wang
- Department of Neurology, Beijing Liangxiang Hospital, Beijing, China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital, Tongji Medical College of HUST, Wuhan, China
| | - Haihua Yang
- Department of Neurology, Beijing Daxing People's Hospital, Beijing, China
| | - Ruile Shen
- Department of Neurology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Zhilin Wu
- Department of Neurointerventional Radiology, YunFu People's Hospital, YunFu, China
| | - Zhengzhou Yuan
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Dongjun Wan
- Department of Neurology, The 940th Hospital of Joint Logistics Support force of Chinese People's Liberation Army, Lanzhou, China
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yan Liu
- Department of Neurology, JingJiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, JingJiang, China
| | - Ping Jing
- Department of Neurology, Wuhan Central Hospital, Wuhan, China
| | - Liping Wei
- Department of Neurology, Luoyang Central Hospital, Luoyang, China
| | - Tuanyuan Zheng
- Department of Neurology, JiuJiang First People's Hospital, JiuJiang, China
| | - Yingchun Wu
- Department of Neurology, Ordos Central Hospital, Ordos, China
| | - Xinguang Yang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Mingze Chang
- Department of Neurology, Xi'an Third Hospital, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Di Li
- Department of Neurointerventional Radiology, Dalian Municipal Central Hospital, Dalian Medical University, Dalian, China
| | - Jixin Duan
- Department of Neurosurgery, Changsha Hospital of Traditional Chinese Medicine, Changsha, China
| | - Dianjing Sun
- Department of Neurointerventional Radiology, Yantai Mountain Hospital of Yantai City, Yantai, China
| | - Zaiyu Guo
- Center for Neurology, Tianjin TEDA Hospital, Tianjin, China
| | - Guodong Xu
- Department of Neurointerventional Radiology, Heibei Provincial People's Hospital, Shijiazhuang, China
| | - Guoqing Wang
- Department of Neurology, Binzhou People's Hospital, Binzhou, China
| | - Liyu Wang
- Department of Neurointerventional Radiology, Beijing Shunyi Hospital, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Hospital, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, JingJiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, JingJiang, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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6
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Guo C, Li L, Huang J, Yang J, Song J, Huang J, Peng Z, Yu N, Liu C, Kong W, Hu J, Chen L, Guo M, Yue C, Yang D, Liu X, Miao J, Wang M, Luo X, Tang Z, Bai X, Wang D, Li F, Yang Q, Zi W. Endovascular treatment versus standard medical treatment in patients with established large infarct: a cohort study. Int J Surg 2024; 110:4775-4784. [PMID: 38716876 PMCID: PMC11326037 DOI: 10.1097/js9.0000000000001539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/15/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Previous trials confirmed the benefit of endovascular treatment (EVT) in acute large core stroke, but the effect of EVT on outcomes in these patients based on noncontrast computed tomography (NCCT) in real-world clinical practice was unclear. The aim of this study was to explore the effect of EVT versus standard medical treatment (SMT) in patients with large ischemic core stroke defined as Alberta Stroke Program Early CT Score (ASPECTS) ≤5 based on NCCT alone. MATERIALS AND METHODS Patients with acute large core stroke at 38 Chinese centers between November 2021 and February 2023 were reviewed from a prospectively maintained database. The primary outcome was favorable functional outcome [modified Rankin Scale score (mRS), 0-3] at 90 days. Safety outcomes included 48 h symptomatic intracerebral hemorrhage (sICH) and 90-day mortality. RESULTS Of 745 eligible patients recruited at 38 stroke centers between November 2021 and February 2023, 490 were treated with EVT+SMT and 255 with SMT alone. One hundred and eighty-one (36.9%) in the EVT group achieved favorable functional independence versus 48 (18.8%) treated with SMT only [adjusted risk ratio (RR), 1.86; 95% CI: 1.43-2.42, P <0.001; adjusted risk difference (RD), 13.77; 95% CI: 7.40-20.15, P <0.001]. The proportion of sICH was significantly higher in patients undergoing EVT (13.3 vs. 2.4%; adjusted RR, 5.17; 95% CI: 2.17-12.32, P <0.001; adjusted RD, 10.10; 95% CI: 6.12-14.09, P <0.001). No significant difference of mortality between the groups was observed (41.8 vs. 49.0%; adjusted RR, 0.91; 95% CI: 0.77-1.07, P =0.24; adjusted RD, -5.91; 95% CI: -12.91-1.09, P =0.1). CONCLUSION Among patients with acute large core stroke based on NCCT in real-world, EVT is associated with better functional outcomes at 90 days despite of higher risk of sICH. Rates of procedure-related complications were relatively higher in the EVT+SMT group.
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Affiliation(s)
- Changwei Guo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Jiandi Huang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Zhouzhou Peng
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Nizhen Yu
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Chang Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Li Chen
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Meng Guo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Dahong Yang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Xiang Liu
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Jian Miao
- Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang
| | - Mengmeng Wang
- Department of Neurology, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Shandong
- Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, People's Republic of China
| | - Xiangyun Luo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Zhaoyin Tang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Xiubing Bai
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Duolao Wang
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University
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7
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Chen K, Zhou Y, Guo G, Wu Q. Single-Centre Experience with Endovascular Therapy in Acute Occlusion of ICAS: Preferred Stent Thrombectomy Versus Preferred Angioplasty. Neurologist 2024:00127893-990000000-00147. [PMID: 39044683 DOI: 10.1097/nrl.0000000000000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
OBJECTIVES The preferred endovascular therapy (EVT) for large-vessel occlusion in intracranial atherosclerosis (ICAS) is unknown. We compared the efficacy of preferred stent thrombectomy and preferred angioplasty in patients with acute large-vessel occlusion in ICAS. METHODS Data from consecutive EVT patients (May 2020 to September 2023) with acute middle cerebral artery occlusion in ICAS were retrospectively analyzed. Preferred angioplasty was performed if there was a preoperative "microcatheter first-pass effect;" otherwise, preferred stent thrombectomy was performed. Analyses were grouped according to the two EVT treatments. Clinical data of all patients, including the time from puncture to recanalization, rate of successful reperfusion, early neurological improvement, intracranial hemorrhage, and modified Rankin Scale score at 90 days, were recorded and analyzed. RESULTS Six-two patients were enrolled in this study (mean age was 60.66±13.21 y, 22.6% female). The preferred angioplasty group had a higher first-pass recanalization rate than the preferred stent thrombectomy group (61.3% vs. 21.9%, P<0.001) and a higher proportion of patients who were functionally independent (defined as a modified Rankin Scale score of 0 to 3) at 90 days [odds ratio,3.681; 95% confidence interval (CI):1.009 to 13.428; P=0.048]. There was no significant difference between the groups in the time from puncture to recanalization, the frequency of successful reperfusion, and early neurological improvement, or intracranial hemorrhage (P>0.05). CONCLUSIONS This study suggests that for acute middle cerebral artery occlusion in ICAS, preferred angioplasty may be a safe and effective procedure.
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Affiliation(s)
- Kechun Chen
- Department of Neurology, Zhangjiagang Hospital affiliated to Soochow University, Zhangjiagang, China
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8
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Gupta D, D’Anna L, Klein P, Araujo-Contreras R, Kaliaev A, Abdalkader M, Hu W, Nguyen TN. Endovascular Treatment for Basilar Artery Occlusion. J Clin Med 2024; 13:4153. [PMID: 39064193 PMCID: PMC11278164 DOI: 10.3390/jcm13144153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/24/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024] Open
Abstract
Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for acute ischemic stroke, IVT has been progressively combined with EVT, which has emerged from recent studies demonstrating clinical benefits, notably in patients presenting with severe stroke. Several randomised controlled trials have shown that EVT improves patient outcomes in select clinical contexts. Future research directions could address therapeutic treatment thresholds, combination strategies, and long-term outcomes.
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Affiliation(s)
- Devansh Gupta
- Smt. Kashibai Navale Medical College and General Hospital, Pune 411041, India;
| | | | - Piers Klein
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (P.K.); (R.A.-C.)
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (A.K.); (M.A.)
| | - Robert Araujo-Contreras
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (P.K.); (R.A.-C.)
| | - Artem Kaliaev
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (A.K.); (M.A.)
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (A.K.); (M.A.)
| | - Wei Hu
- The First Affiliated Hospital of University of Science and Technology of China, Hefei 230026, China;
| | - Thanh N. Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (P.K.); (R.A.-C.)
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (A.K.); (M.A.)
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9
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A Tarek M, Damiani Monteiro M, Mohammaden MH, Martins PN, Sheth SA, Dolia J, Pabaney A, Grossberg JA, Nahhas M, A De La Garza C, Salazar-Marioni S, Rangaraju S, Nogueira RG, Haussen DC. Development and validation of a SCORing systEm for pre-thrombectomy diagnosis of IntraCranial Atherosclerotic Disease (Score-ICAD). J Neurointerv Surg 2024:jnis-2024-021676. [PMID: 38782568 DOI: 10.1136/jnis-2024-021676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Early identification of intracranial atherosclerotic disease (ICAD) may impact the management of patients undergoing mechanical thrombectomy (MT). We sought to develop and validate a scoring system for pre-thrombectomy diagnosis of ICAD in anterior circulation large vessel/distal medium vessel occlusion strokes (LVOs/DMVOs). METHODS Retrospective analysis of two prospectively maintained comprehensive stroke center databases including patients with anterior circulation occlusions spanning 2010-22 (development cohort) and 2018-22 (validation cohort). ICAD cases were matched for age and sex (1:1) to non-ICAD controls. RESULTS Of 2870 MTs within the study period, 348 patients were included in the development cohort: 174 anterior circulation ICAD (6% of 2870 MTs) and 174 controls. Multivariable analysis β coefficients led to a 20 point scale: absence of atrial fibrillation (5); vascular risk factor burden (1) for each of hypertension, diabetes, smoking, and hyperlipidemia; multifocal single artery stenoses on CT angiography (3); absence of territorial cortical infarct (3); presence of borderzone infarct (3); or ipsilateral carotid siphon calcification (2). The validation cohort comprised 56 ICAD patients (4.1% of 1359 MTs): 56 controls. Area under the receiver operating characteristic curve was 0.88 (0.84-0.91) and 0.82 (0.73-0.89) in the development and validation cohorts, respectively. Calibration slope and intercept showed a good fit for the development cohort although with overestimated risk for the validation cohort. After intercept adjustment, the overestimation was corrected (intercept 0, 95% CI -0.5 to -0.5; slope 0.8, 95% CI 0.5 to 1.1). In the full cohort (n=414), ≥11 points showed the best performance for distinguishing ICAD from non-ICAD, with 0.71 (95% CI 0.65 to 0.78) sensitivity and 0.82 (95% CI 0.77 to 0.87) specificity, and 3.92 (95% CI 2.92 to 5.28) positive and 0.35 (95% CI 0.28 to 0.44) negative likelihood ratio. Scores ≥12 showed 90% specificity and 63% sensitivity. CONCLUSION The proposed scoring system for preprocedural diagnosis of ICAD LVOs and DMVOs presented satisfactory discrimination and calibration based on clinical and non-invasive radiological data.
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Affiliation(s)
- Mohamed A Tarek
- Neurology Department, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology and Psychological Medicine, Sohag University Faculty of Medicine, Sohag, Egypt
| | - Mateus Damiani Monteiro
- Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Health System Marcus Stroke and Neuroscience Center, Atlanta, Georgia, USA
| | | | - Pedro N Martins
- Neurology Department, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Health System Marcus Stroke and Neuroscience Center, Atlanta, Georgia, USA
| | - Sunil A Sheth
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jaydevsinh Dolia
- Neurology Department, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael Nahhas
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Carlos A De La Garza
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Srikant Rangaraju
- Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Diogo C Haussen
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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10
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Xie D, Huang J, Fan S, Guo C, Sun W, Peng Z, Zhang L, Yue C, Qiu Z, Sang H, Liang D, Hu J, Yang J, Huang J, Li L, Liu J, Yang D, Liu X, Kong W, Liu S, Yang Q, Zi W, Li F. Endovascular Therapy and Outcomes Among Patients With Very Large Ischemic Core Stroke. JAMA Netw Open 2024; 7:e249298. [PMID: 38696171 PMCID: PMC11066696 DOI: 10.1001/jamanetworkopen.2024.9298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/04/2024] [Indexed: 05/05/2024] Open
Abstract
Importance The association of endovascular therapy (EVT) with outcomes is unclear for patients with very low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) within 24 hours of stroke onset. Objective To explore the association of EVT with functional and safety outcomes among patients with ASPECTS of 0 to 2 scored with noncontrast computed tomography. Design, Setting, and Participants This cohort study used data from an ongoing, prospective, observational, nationwide registry including all patients treated at 38 stroke centers in China with an occlusion in the internal carotid artery or M1 or M2 segment of the middle cerebral artery within 24 hours of witnessed symptom onset. Patients with ASPECTS of 0 to 2 between November 1, 2021, and February 8, 2023, were included in analysis. Data were analyzed October to November 2023. Exposures EVT vs standard medical treatment (SMT). Main Outcomes and Measures The primary outcome was favorable functional outcome, defined as modified Rankin Scale score (mRS) of 0 to 3, at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (sICH) within 48 hours and mortality at 90 days. Results A total of 245 patients (median [IQR] age, 71 [63-78] years; 118 [48%] women) with ASPECTS of 0 to 2 were included, of whom 111 patients (45.1%) received SMT and 135 patients (54.9%) received EVT. The EVT group had significantly greater odds of favorable functional outcome at 90 days than the SMT group (30 patients [22.2%] vs 11 patients [9.9%]; P = .01; adjusted odds ratio [aOR], 3.07 [95% CI, 1.29-7.31]; P = .01). Patients in the EVT group, compared with the SMT group, had significantly greater odds of any ICH (56 patients [41.5%] vs 16 patients [11.4%]; P < .001; aOR, 4.27 [95% CI, 2.19-8.35]; P < .001) and sICH (24 patients [17.8%] vs 1 patient [0.9%]; P < .001; aOR, 23.07 [95% CI, 2.99-177.79]; P = .003) within 48 hours. There were no differences between groups for 90-day mortality (80 patients [59.3%] vs 59 patients [53.2%]; P = .34; aOR, 1.38 [95% CI, 0.77-2.47]; P = .28). The results remained robust in the propensity score-matched analysis. Conclusions and Relevance In this cohort study of patients with very low ASPECTS based on NCCT within 24 hours of stroke onset, those treated with EVT had higher odds of a favorable functional outcome compared with those who received SMT. Randomized clinical trials are needed to assess these findings.
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Affiliation(s)
- Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shitao Fan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenzhe Sun
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhouzhou Peng
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Lingyu Zhang
- Department of Neurology, Weifang Medical University, Weifang, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dingwen Liang
- Department of Neurology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiandi Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Juan Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dahong Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiang Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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11
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Lin MS, Huang CW, Tsuei YS. Clinical experience in intracranial stenting of Wingspan stent system under local anesthesia. Front Neurol 2024; 15:1348779. [PMID: 38585355 PMCID: PMC10995349 DOI: 10.3389/fneur.2024.1348779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Objective The use of endovascular treatments for symptomatic intracranial atherosclerosis disease (ICAD) remains contentious due to high periprocedural complications. Many centers resort to general anesthesia for airway protection and optimal periprocedural conditions; however, this approach lacks real-time monitoring of patients' neurological status during procedures. In this study, we employed intracranial stenting with the Wingspan system under local anesthesia to address this challenge. Methods We conducted a retrospective study of 45 consecutive ICAD patients who underwent intracranial stenting with the Wingspan system at our hospital from August 2013 to May 2021. These stenting procedures were performed under local anesthesia in a hybrid operation room. Neurological assessments were conducted during the procedure. The patients with periprocedural complications were analyzed for the risk factors. Results The study included 45 ICAD patients (median age 62 years; 35 male and 10 female individuals). Among them, 30 patients had anterior circulation ICAD, and 15 had posterior circulation ICAD. The periprocedural complication rate was 8.9% (4/45), with an overall mortality rate of 2.2% (1/45). Notably, no procedure-related perforation complications were found, and all ischemic complications occurred in the perforating bearing artery, specifically in patients with stents placed in the middle cerebral artery or basilar artery, while no complications were observed in the non-perforating bearing artery of the internal carotid artery and vertebral artery (p = 0.04). Conclusion Our study demonstrates the safety and efficacy of the Wingspan stent system when performed on selected patients under local anesthesia. This approach seems to reduce procedural-related morbidity and be a safe intervention. In addition, it is crucial for surgeons to be aware that patients with perforator-bearing artery stenosis may be at a higher risk of complications.
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Affiliation(s)
- Mao-Shih Lin
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chih-Wei Huang
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yuang-Seng Tsuei
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Neurosurgery, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan
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12
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Zhang L, He X, Li K, Ling L, Peng M, Huang L, Liu Y. Balloon angioplasty as first-choice recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion with small clot burden. Neuroradiology 2024; 66:399-407. [PMID: 38183425 DOI: 10.1007/s00234-023-03278-8] [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: 05/14/2023] [Accepted: 12/22/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE The optimal primary recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) remains controversial. We aimed to explore the safety and efficacy of balloon angioplasty as the first-choice recanalization strategy for ICAS-ELVO with small clot burden. METHODS Consecutive ICAS-ELVO patients presenting with microcatheter "first-pass effect" during endovascular treatment (EVT) were retrospectively analyzed. Patients were divided into preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT) groups based on the first-choice recanalization strategy. The reperfusion and clinical outcomes between the two groups were compared. RESULTS Seventy-six patients with ICAS-ELVO involving the microcatheter "first-pass effect" during EVT were enrolled. Compared with patients in the PMT group, those in the PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p = .010) and complete reperfusion (expanded thrombolysis in cerebral ischemia ≥ 2c; 76.0% vs. 53.8%, p = .049), (ii) shorter puncture-to-recanalization time (49.5 min vs. 89.0 min, p < .001), (iii) lower operation costs (¥48,499.5 vs. ¥ 99,086.0, p < .001), and (iv) better 90-day functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p = .032). Logistic regression analysis revealed that balloon angioplasty as the first-choice recanalization strategy was an independent predictor of 90-day excellent functional outcomes for ICAS-ELVO patients with microcatheter "first-pass effect" (adjusted odds ratio = 6.01, 95% confidence interval: 1.15-31.51, p = .034). CONCLUSION Direct balloon angioplasty potentially improves 90-day functional outcomes for ICAS-ELVO patients with small clot burden, and may be a more appropriate first-choice recanalization strategy than mechanical thrombectomy for these patients.
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Affiliation(s)
- Liang Zhang
- Department of Neurology, First Affiliated Hospital of Jinan University, NO 613 West Huangpu Rd, Tianhe Dt, Guangzhou, 510630, China
| | - Xiong'jun He
- Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China
| | - Kai'feng Li
- Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China
| | - Li Ling
- Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China
| | - Min Peng
- Department of Neurology, First Affiliated Hospital of Jinan University, NO 613 West Huangpu Rd, Tianhe Dt, Guangzhou, 510630, China
| | - Li'an Huang
- Department of Neurology, First Affiliated Hospital of Jinan University, NO 613 West Huangpu Rd, Tianhe Dt, Guangzhou, 510630, China.
| | - Ya'jie Liu
- Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China.
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13
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Rodrigo-Gisbert M, García-Tornel A, Requena M, Vielba-Gómez I, Bashir S, Rubiera M, De Dios Lascuevas M, Olivé-Gadea M, Piñana C, Rizzo F, Muchada M, Rodriguez-Villatoro N, Rodríguez-Luna D, Juega J, Pagola J, Hernández D, Molina CA, Terceño M, Tomasello A, Ribo M. Clinico-radiological features of intracranial atherosclerosis-related large vessel occlusion prior to endovascular treatment. Sci Rep 2024; 14:2945. [PMID: 38316891 PMCID: PMC10844212 DOI: 10.1038/s41598-024-53354-z] [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: 09/15/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024] Open
Abstract
The identification of large vessel occlusion with underlying intracranial atherosclerotic disease (ICAS-LVO) before endovascular treatment (EVT) continues to be a challenge. We aimed to analyze baseline clinical-radiological features associated with ICAS-LVO that could lead to a prompt identification. We performed a retrospective cross-sectional study of consecutive patients with stroke treated with EVT from January 2020 to April 2022. We included anterior LVO involving intracranial internal carotid artery and middle cerebral artery. We analyzed baseline clinical and radiological variables associated with ICAS-LVO and evaluated the diagnostic value of a multivariate logistic regression model to identify ICAS-LVO before EVT. ICAS-LVO was defined as presence of angiographic residual stenosis or a trend to re-occlusion during EVT procedure. A total of 338 patients were included in the study. Of them, 28 patients (8.3%) presented with ICAS-LVO. After adjusting for confounders, absence of atrial fibrillation (OR 9.33, 95% CI 1.11-78.42; p = 0.040), lower hypoperfusion intensity ratio (HIR [Tmax > 10 s/Tmax > 6 s ratio], (OR 0.69, 95% CI 0.50-0.95; p = 0.025), symptomatic intracranial artery calcification (IAC, OR .15, 95% CI 1.64-26.42, p = 0.006), a more proximal occlusion (ICA, MCA-M1: OR 4.00, 95% CI 1.23-13.03; p = 0.021), and smoking (OR 2.91, 95% CI 1.08-7.90; p = 0.035) were associated with ICAS-LVO. The clinico-radiological model showed an overall well capability to identify ICAS-LVO (AUC = 0.88, 95% CI 0.83-0.94; p < 0.001). In conclusion, a combination of clinical and radiological features available before EVT can help to identify an ICAS-LVO. This approach could be useful to perform a rapid assessment of underlying etiology and suggest specific pathophysiology-based measures. Prospective studies are needed to validate these findings in other populations.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Isabel Vielba-Gómez
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Saima Bashir
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Piñana
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Rodríguez-Luna
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesus Juega
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Hernández
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mikel Terceño
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Alejandro Tomasello
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
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14
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Al Kasab S, Nguyen TN, Derdeyn CP, Yaghi S, Amin-Hanjani S, Kicielinski K, Zaidat OO, de Havenon A. Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions. Stroke 2024; 55:355-365. [PMID: 38252763 DOI: 10.1161/strokeaha.123.043635] [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: 08/01/2023] [Accepted: 10/12/2023] [Indexed: 01/24/2024]
Abstract
This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology (S.A.K.), Medical University of South Carolina, Charleston
- Department of Neurosurgery (S.A.K., K.K.), Medical University of South Carolina, Charleston
| | | | - Colin P Derdeyn
- Department of Radiology, Carver College of Medicine, Iowa City (C.P.D.)
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y.)
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, OH (S.A.-H.)
| | - Kimberly Kicielinski
- Department of Neurosurgery (S.A.K., K.K.), Medical University of South Carolina, Charleston
| | - Osama O Zaidat
- Department of Neurology, Mercy Health, Toledo, OH (O.O.Z.)
| | - Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, CT (A.d.H.)
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15
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Ojeda DJ, Ghannam M, Sanchez S, Almajali M, Koul P, Saver JL, Gupta R, Ortega-Gutierrez S, Liebeskind DS, Samaniego EA. Tigertriever in the treatment of acute ischemic stroke with underlying intracranial atherosclerotic disease. J Neurointerv Surg 2024:jnis-2023-020796. [PMID: 37777257 DOI: 10.1136/jnis-2023-020796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/10/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND The Tigertriever device offers a unique feature that enables gradual control of the radial expansion. We sought to evaluate the safety and efficacy of the Tigertriever device in patients with large vessel occlusion (LVO) and underlying intracranial atherosclerotic disease (ICAD). The patients were part of the TIGER trial. METHODS The presence of underlying ICAD was determined by a core imaging laboratory using CT angiography and digital subtraction angiography. The primary outcomes included successful reperfusion, puncture to reperfusion time, and complications associated with the use of the Tigertriever device. Patients underwent mechanical thrombectomy with the Tigertriever device for up to three passes, and alternative devices were employed for subsequent passes. RESULTS A total of 160 patients were enrolled in the TIGER trial, and 32 patients had ICAD. Among the patients with ICAD, 78% achieved successful reperfusion within three passes of the Tigertriever device, without requiring rescue therapy. Additionally, a first pass effect was observed in 46.8%. The median time from puncture to reperfusion was 22 minutes. There were no device-related complications. The National Institutes of Health Stroke Scale (NIHSS) score at 24 hours was significantly reduced, from an average of 17 at baseline to 8. At the 3 month follow-up, 50% of patients achieved a modified Rankin Scale score of ≤2. CONCLUSION Endovascular therapy (EVT) with the Tigertriever device for LVO in patients with underlying ICAD is effective and safe. When compared with historical data from other devices employed in similar cases, we observed a high rate of successful reperfusion, along with a shorter puncture to reperfusion time.
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Affiliation(s)
- Diego J Ojeda
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Malik Ghannam
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sebastian Sanchez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mohammad Almajali
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Prateeka Koul
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jeffrey L Saver
- Neurology and Comprehensive Stroke Center, University of California Los Angeles, Los Angeles, California, USA
| | - Rishi Gupta
- Neurosurgery, WellStar Medical Group, Marietta, Georgia, USA
| | | | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Edgar A Samaniego
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa City, Iowa, USA
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16
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Koh S, Park SY, Liebeskind DS, Choi JW, Kim HK, Choi JY, Kim M, Lee S, Hong JM, Lee JS. Prediction of Intracranial Atherosclerotic Disease-Related Large-Vessel Occlusion Stroke on the Basis of Novel Cerebral Blood Volume Parameters. J Am Heart Assoc 2024; 13:e030936. [PMID: 38214247 PMCID: PMC10926804 DOI: 10.1161/jaha.123.030936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/23/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Mechanical thrombectomy is an effective treatment method for large-vessel occlusion stroke (LVOS); however, it has limited efficacy for intracranial atherosclerotic disease (ICAD)-related LVOS. We investigated the use of cerebral blood volume (CBV) maps for identifying ICAD as the underlying cause of LVOS before the initiation of endovascular treatment (EVT). METHODS AND RESULTS We reviewed clinical and imaging data from patients who presented with LVOS and underwent endovascular treatment between January 2011 and May 2021. The CBV patterns were analyzed to identify an increase in CBV within the hypoperfused area and estimate infarct patterns within the area of decreased CBV. Comparisons were made between the patients with an increase in CBV and those without, and among the estimated infarct patterns: territorial, cortical wedge, basal ganglia-only, subcortical, and normal CBV. Overall, 243 patients were included. CBV increase in the hypoperfused area was observed in 23.5% of patients. A significantly higher proportion of ICAD was observed in those with increased CBV than in those without (56.4% versus 19.8%; P<0.001). Regarding the estimated infarct patterns on the CBV, ICAD was most frequently observed in the normal CBV group (territorial, 14.9%; cortical wedge, 10.0%; basal ganglia-only, 43.8%; subcortical, 35.7%; normal, 61.7%). CBV parameters, including "an increase in CBV," "normal CBV infarct pattern," and "an increase in CBV or normal CBV infarct pattern composite," were independently associated with ICAD. CONCLUSIONS An increased CBV or normal CBV pattern may be associated with ICAD LVOS on the pretreatment perfusion imaging.
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Affiliation(s)
- Seungyon Koh
- Department of Brain ScienceAjou University School of MedicineSuwonRepublic of Korea
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - So Young Park
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | | | - Jin Wook Choi
- Department of Radiology, Ajou University School of MedicineAjou University HospitalSuwonRepublic of Korea
| | - Han Ki Kim
- Department of Brain ScienceAjou University School of MedicineSuwonRepublic of Korea
| | - Jun Young Choi
- Department of Brain ScienceAjou University School of MedicineSuwonRepublic of Korea
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - Min Kim
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - Seong‐Joon Lee
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - Ji Man Hong
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - Jin Soo Lee
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
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17
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Brake A, Heskett C, Alam N, Fry L, Le K, Mahnken JD, Abraham M. Glycoprotein inhibitors as a first line rescue treatment after unsuccessful recanalization of endovascular thrombectomy: A systematic review and meta-analysis. Interv Neuroradiol 2024:15910199241226470. [PMID: 38204180 DOI: 10.1177/15910199241226470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Intracranial atherosclerotic disease (ICAD) is a major cause of stroke with a high rate of re-occlusion following mechanical thrombectomy (MT). Among the available rescue options, glycoprotein IIb/IIIa inhibitors (GPI) have shown promise as a potential therapeutic strategy. This systematic review and meta-analysis examine studies exploring the use of glycoprotein inhibitors as a first-line treatment for refractory occlusion or high-grade stenosis following EVT in the setting of ICAD. METHODS A systematic review and meta-analysis were performed. Studies using GPI as the first-line rescue treatment (GPI-rt) after failed thrombectomy or in the setting with high-grade stenosis (>50%) were included. The primary outcome of interest was good clinical outcomes (defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days). Secondary outcomes of interest were successful recanalization (TICI 2b-3), symptomatic intracranial hemorrhage (sICH), and mortality by 90 days. RESULTS Our study processed 2111 articles, which yielded eight relevant studies for review, four single and four double arm. These studies comprised 763 patients, divided into GPI-rt (535 patients) and non-GPI-rt (228 patients) cohorts. The GPI-rt group had higher rates of mRS ≤ 2 at 90 days (58.5% vs 38.9%, p = 0.002) and lower mortality rates (7.8% vs 17.5%, p = 0.04) compared to the non-GPI-rt cohort. mTICI 2b-3 rates and rates of sICH were not significantly different between the cohorts. CONCLUSIONS First line GPI-rt demonstrates significant clinical benefit and significantly lower mortality without a rise in rates of sICH. GPI are a potential first line rescue treatment of ICAD.
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Affiliation(s)
- Aaron Brake
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Cody Heskett
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Naima Alam
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lane Fry
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Kevin Le
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Jonathan D Mahnken
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael Abraham
- Department of Neurology, University of Kansas Health System, Kansas City, KS, USA
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18
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Safouris A, Psychogios K, Palaiodimou L, Orosz P, Magoufis G, Kargiotis O, Theodorou A, Karapanayiotides T, Spiliopoulos S, Nardai S, Sarraj A, Nguyen TN, Yaghi S, Walter S, Sacco S, Turc G, Tsivgoulis G. Update of Anticoagulation Use in Cardioembolic Stroke With a Special Reference to Endovascular Treatment. J Stroke 2024; 26:13-25. [PMID: 38326704 PMCID: PMC10850459 DOI: 10.5853/jos.2023.01578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 02/09/2024] Open
Abstract
Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | | | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Orosz
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - George Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | | | - Aikaterini Theodorou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | - Sándor Nardai
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Thanh N. Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
- Université Paris Cité, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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19
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Kim SJ, English SW, Chester KW, Morgan OJ, Frankel MR, Nogueira RG, Al-Bayati AR, Haussen DC. Emergent use of ticagrelor during endovascular reperfusion in large arterial occlusions. J Stroke Cerebrovasc Dis 2023; 32:107351. [PMID: 37837802 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107351] [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: 03/14/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 10/16/2023] Open
Abstract
OBJECTIVE Given many emerging indications for endovascular interventions in ischemic strokes, a safe and effective adjuvant antiplatelet regimen for acute revascularization has become a subject of interest. Ticagrelor is a direct oral P2Y12 inhibitor that may achieve rapid platelet suppression than standard oral therapies. We report our experience of Ticagrelor use in revascularization of acute large arterial steno-occlusive disease, describing procedural post-procedure thrombotic events, major hemorrhages, and other clinical outcomes. METHODS This was a single-center retrospective case series of large steno-occlusive disease requiring endovascular reperfusion with emergent adjuvant Ticagrelor, defined as 30 min of the procedure from skin puncture to closure of the arteriotomy. Major outcomes investigated were thromboembolism in the target artery, and symptomatic intracranial or extracranial major hemorrhages. Additional analyses were performed with respect to timing of the administration and use of rescue GPIIb/IIIa inhibitors if any. RESULTS 73 consecutive patients were identified, presenting with severe ischemic stroke (median NIHSS 16) of large artery origin. 67% required stent placement (45% cervical carotid, 22% intracranial artery), 9.5% angioplasty and 23% mechanical thrombectomy only. Two experienced symptomatic in-stent occlusion, and 7 experienced major hemorrhages (9.5%) including 3 fatal symptomatic intracranial hemorrhages (4.1%). Among 19 subjects (26%) who received pretreatment with Ticagrelor, there were fewer GPIIb/IIIa administration, angioplasty and stenting, without yielding benefit in functional outcome or mortality. GPIIb/IIIa was administered as rescue therapy in 45 subjects (62%), which was found associated with increased bleeding compared to patients receiving Ticagrelor only, in whom no bleeding complications were recorded (16% vs. 0%; p = 0.03). CONCLUSION We report our findings on Ticagrelor as an adjuvant antiplatelet therapy in ischemic stroke of large arterial origin requiring emergent revascularization. Effectiveness, safety, need for additional rescue treatment, and comparison to other commonly used oral antiplatelets should be investigated in future prospective studies.
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Affiliation(s)
- Song J Kim
- Department of Neurology, California Pacific Medical Center/Sutter Health, San Francisco, CA, USA.
| | | | - Katleen W Chester
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA, USA
| | - Olivia J Morgan
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA, USA
| | - Michael R Frankel
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA, USA
| | - Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
| | - Alhamza R Al-Bayati
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA, USA
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20
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Jia B, Zhang L, Pan Y, Tong X, Zhang X, Mo D, Ma N, Luo G, Song L, Li X, Wang B, Nguyen TN, Gao F, Miao Z. Rescue angioplasty and/or stenting after mechanical thrombectomy: who can benefit? J Neurointerv Surg 2023:jnis-2023-020824. [PMID: 38050150 DOI: 10.1136/jnis-2023-020824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/25/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Angioplasty and/or stenting is a rescue therapy for mechanical thrombectomy (MT) in acute intracranial large vessel occlusion. This study was undertaken to determine whether rescue angioplasty and/or stenting improves the outcome after MT and to investigate whether outcomes differ by subgroup of rescue indication. METHODS We performed propensity score matching (PSM) with data from a prospective multicenter registry of patients with acute large vessel occlusion receiving endovascular treatment. Patients were divided into the MT alone group and the MT with rescue therapy group. The primary outcome was functional independence (modified Rankin Scale score of 0-2) at 90 days. PSM was also performed in the failed MT (modified Thrombolysis In Cerebral Infarction (mTICI) 0-2a) and the residual severe stenosis (mTICI 2b-3) subgroups, respectively. RESULTS 326 patients of mean±SD age 62.7±12.0 years (90 women, 27.6%) were matched from 1274 patients. In the matched cohort, functional independence at 90 days was higher in the rescue therapy group than in the MT alone group (44.2% vs 29.5%; OR 1.90, 95% CI 1.18 to 3.06, P=0.008). In the failed MT subgroup with 66 matched pairs, more patients had functional independence in the rescue therapy group than in the MT alone group (39.0% vs 17.0%; OR 3.12, 95% CI 1.29 to 7.59, P=0.01). In the residual stenosis subgroup with 63 matched pairs, functional independence rates were similar in the rescue therapy and the MT alone groups (51.6% vs 55.7%; OR 0.85, 95% CI 0.42 to 1.72, P=0.65). CONCLUSION Rescue angioplasty and/or stenting could improve the clinical outcome in patients with acute large vessel occlusion with failed MT, while no benefit was seen in those with residual severe stenosis but substantial reperfusion.
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Affiliation(s)
- BaiXue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Longhui Zhang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuelei Zhang
- Stroke Center, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Li
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Wang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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21
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Bhenderu LS, Hardigan T, Roa J, Philbrick BD, Hoang A, Faraji AH, Britz GW, Yaeger KA. United States regulatory approval of medical devices used for endovascular neurosurgery: A two-decade review of FDA regulatory files. J Neurointerv Surg 2023:jnis-2023-020703. [PMID: 37923383 DOI: 10.1136/jnis-2023-020703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The evolution of neuroendovascular technologies has progressed substantially. Over the last two decades, the introduction of new endovascular devices has facilitated treatment for more patients, and as a result, the regulatory environment concerning neuroendovascular devices has evolved rapidly in response. OBJECTIVE To examine trends in the approval of neuroendovascular devices by the United States Food and Drug Administration (FDA) over the last 20 years. METHODS Open-access US FDA databases were queried between January 2000 and December 2022 for all devices approved by the Neurological Devices Advisory Committee. Neuroendovascular devices were manually classified and grouped by category. Device approval data, including approval times, approval pathway, and presence of predicate devices, were examined. RESULTS A total of 3186 neurological devices were approved via various US FDA pathways during the study period. 320 (10.0%) corresponded to neuroendovascular devices, of which 301 (94.1%) were approved via the 510(k) pathway. The percentage of 510(k) pathway neuroendovascular devices increased from 6.9% to 14.3% of all neuro devices before and after 2015, respectively. There was an increase in approval times for neuroendovascular devices cleared after 2015. CONCLUSION Over the last two decades, the neuroendovascular device armamentarium has rapidly expanded, especially after positive stroke trials in 2015. Regulatory approval times are significantly affected by device category, generation, company size, and company location, and a vast majority are approved by the 510(k) pathway. These results can guide further innovation in the endovascular device space and may act as a roadmap for future regulatory planning.
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Affiliation(s)
- Lokeshwar S Bhenderu
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
- Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas, USA
- Center for Translational Neural Prosthetics and Interfaces, Houston Methodist Research Institute, Houston, Texas, USA
| | - Trevor Hardigan
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Jorge Roa
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Brandon D Philbrick
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Alex Hoang
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
- Center for Translational Neural Prosthetics and Interfaces, Houston Methodist Research Institute, Houston, Texas, USA
| | - Amir H Faraji
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
- Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas, USA
- Center for Translational Neural Prosthetics and Interfaces, Houston Methodist Research Institute, Houston, Texas, USA
| | - Gavin W Britz
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
- Center for Translational Neural Prosthetics and Interfaces, Houston Methodist Research Institute, Houston, Texas, USA
| | - Kurt A Yaeger
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
- Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas, USA
- Center for Translational Neural Prosthetics and Interfaces, Houston Methodist Research Institute, Houston, Texas, USA
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22
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Ahmed R, Maqsood H, Bains RS, Gulraiz A, Kamal M. Intracranial atherosclerotic disease: current management strategies. Ann Med Surg (Lond) 2023; 85:4903-4908. [PMID: 37811034 PMCID: PMC10552953 DOI: 10.1097/ms9.0000000000001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/01/2023] [Indexed: 10/10/2023] Open
Abstract
A stroke due to underlying intracranial large artery occlusion, which is atherosclerotic in nature, is known as intracranial atherosclerotic disease (ICAD). It is important to recognize that ischaemic stroke due to ICAD differs from extracranial disease and other stroke aetiologies and requires a nuanced approach. It is a significant cause of stroke worldwide, and severe symptomatic ICAD can present challenges from a therapeutic standpoint, including recurrent ischaemic stroke despite optimal management. Furthermore, exploring the underlying pathophysiological mechanisms responsible for the disease may be necessary while considering treatment options. This narrative review aims to provide an all-encompassing overview of this disease. Epidemiology and clinical pathophysiology will be explored in detail. The findings of large clinical trials will serve as a guide to finding the most optimized management strategies. Another critical question that arises is the treatment of acute ischaemic stroke due to large vessel occlusion with underlying intracranial atherosclerosis, is the treatment and clinical diagnosis the same as for other aetiologies of stroke (i.e. extracranial disease and nonvalvular atrial fibrillation)? Consequently, secondary prevention of patients with ischaemic stroke or transient ischaemic attack will be divided into medical therapy, risk factor control, and endovascular and surgical treatment options.
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Affiliation(s)
| | | | | | | | - Meraj Kamal
- BP Koirala Institute of Health Sciences, Dharan-18, Nepal
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23
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Wang D, Shang ZY, Cui Y, Yang BQ, Ntaios G, Chen HS. Characteristics of intracranial plaque in patients with non-cardioembolic stroke and intracranial large vessel occlusion. Stroke Vasc Neurol 2023; 8:387-398. [PMID: 36914215 PMCID: PMC10648047 DOI: 10.1136/svn-2022-002071] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/26/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To determine the characteristics of intracranial plaque proximal to large vessel occlusion (LVO) in stroke patients without major-risk cardioembolic source using 3.0 T high-resolution MRI (HR-MRI). METHODS We retrospectively enrolled eligible patients from January 2015 to July 2021. The multidimensional parameters of plaque such as remodelling index (RI), plaque burden (PB), percentage lipid-rich necrotic core (%LRNC), presence of discontinuity of plaque surface (DPS), fibrous cap rupture, intraplaque haemorrhage and complicated plaque were evaluated by HR-MRI. RESULTS Among 279 stroke patients, intracranial plaque proximal to LVO was more prevalent in the ipsilateral versus contralateral side to stroke (75.6% vs 58.8%, p<0.001). The larger PB (p<0.001), RI (p<0.001) and %LRNC (p=0.001), the higher prevalence of DPS (61.1% vs 50.6%, p=0.041) and complicated plaque (63.0% vs 50.6%, p=0.016) were observed in the plaque ipsilateral versus contralateral to stroke. Logistic analysis showed that RI and PB were positively associated with an ischaemic stroke (RI: crude OR: 1.303, 95% CI 1.072 to 1.584, p=0.008; PB: crude OR: 1.677, 95% CI 1.381 to 2.037, p<0.001). In subgroup with <50% stenotic plaque, the greater PB, RI, %LRNC and the presence of complicated plaque were more closely related to stroke, which was not evident in subgroup with ≥50% stenotic plaque. CONCLUSION This is the first study to report the characteristics of intracranial plaque proximal to LVO in non-cardioembolic stroke. It provides potential evidence to support different aetiological roles of <50% stenotic vs ≥50% stenotic intracranial plaque in this population.
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Affiliation(s)
- Dan Wang
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - Zi-Yang Shang
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - Ben-Qiang Yang
- Radiology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
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24
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Kishi F, Nakagawa I, Kimura S, Ogawa D, Yagi R, Yamada K, Taniguchi H. Tmax volume can predict clinical type in patients with acute ischemic stroke. Brain Behav 2023; 13:e3163. [PMID: 37469274 PMCID: PMC10454272 DOI: 10.1002/brb3.3163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/15/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023] Open
Abstract
OBJECTIVE Endovascular therapy (EVT) is performed for acute ischemic stroke (AIS) with large vessel occlusion (LVO), however, the treatment strategies and clinical outcomes differ between cardiac embolism (CE) and intracranial arteriosclerosis-derived LVO (ICAS-LVO). We analyzed whether the time-to-max (Tmax) volume derived from perfusion imaging predicted clinical classification in AIS patients before EVT. METHODS Consecutive AIS patients with anterior circulation LVO evaluated by automated imaging software were retrospectively identified. Patients were classified into a CE group and an ICAS-LVO group, and parameters were compared between groups. RESULTS Thirty-nine patients were included and Tmax volume and Tmax > 6 s volume/Tmax > 4 s volume were significantly greater in the CE group than in the ICAS-LVO group (Tmax > 4 s volume: 261 mL vs. 149 mL, p = .01, Tmax > 6 s volume: 143 mL vs. 59 mL, p = .001, Tmax > 6 s volume/Tmax > 4 s volume: 0.59 vs. 0.40, p < .001). Multiple logistic regression analysis indicated an association between clinical classification and high Tmax > 6 s volume/Tmax > 4 s volume (p = .04). CONCLUSION The Tmax volume derived from perfusion imaging predicts the clinical classification of AIS patients before EVT.
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Affiliation(s)
- Fumihisa Kishi
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
| | - Ichiro Nakagawa
- Department of NeurosurgeryNara Medical UniversityKashiharaNaraJapan
| | - Seigo Kimura
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
| | - Daiji Ogawa
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
| | - Ryokichi Yagi
- Department of NeurosurgeryOsaka Medical and Pharmaceutical UniversityTakatsukiOsakaJapan
| | - Keiichi Yamada
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
| | - Hirokatsu Taniguchi
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
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25
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Khachatryan T, Shafie M, Abcede H, Shah J, Nagamine M, Granstein J, Yuki I, Golshani K, Suzuki S, Yu W. Rescue therapy after thrombectomy for large vessel occlusion due to underlying atherosclerosis: review of literature. Front Neurol 2023; 14:1181295. [PMID: 37396754 PMCID: PMC10313123 DOI: 10.3389/fneur.2023.1181295] [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: 03/13/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
Abstract
In this review article, we summarized the current advances in rescue management for reperfusion therapy of acute ischemic stroke from large vessel occlusion due to underlying intracranial atherosclerotic stenosis (ICAS). It is estimated that 24-47% of patients with acute vertebrobasilar artery occlusion have underlying ICAS and superimposed in situ thrombosis. These patients have been found to have longer procedure times, lower recanalization rates, higher rates of reocclusion and lower rates of favorable outcomes than patients with embolic occlusion. Here, we discuss the most recent literature regarding the use of glycoprotein IIb/IIIa inhibitors, angioplasty alone, or angioplasty with stenting for rescue therapy in the setting of failed recanalization or instant/imminent reocclusion during thrombectomy. We also present a case of rescue therapy post intravenous tPA and thrombectomy with intra-arterial tirofiban and balloon angioplasty followed by oral dual antiplatelet therapy in a patient with dominant vertebral artery occlusion due to ICAS. Based on the available literature data, we conclude that glycoprotein IIb/IIIa is a reasonably safe and effective rescue therapy for patients who have had a failed thrombectomy or have residual severe intracranial stenosis. Balloon angioplasty and/or stenting may be helpful as a rescue treatment for patients who have had a failed thrombectomy or are at risk of reocclusion. The effectiveness of immediate stenting for residual stenosis after successful thrombectomy is still uncertain. Rescue therapy does not appear to increase the risk of sICH. Randomized controlled trials are warranted to prove the efficacy of rescue therapy.
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Affiliation(s)
- Tigran Khachatryan
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Mohammad Shafie
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Hermelinda Abcede
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Jay Shah
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Masaki Nagamine
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Justin Granstein
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Ichiro Yuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Shuichi Suzuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
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26
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Asai K, Taniguchi M, Nakamura H, Tateishi A, Irizato N, Okubata H, Fukuya S, Yoshimura K, Yamamoto K, Kishima H, Wakayama A. Safety and Efficacy of Prasugrel Administration in Emergent Endovascular Treatment for Intracranial Atherosclerotic Disease. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:125-131. [PMID: 37546344 PMCID: PMC10400910 DOI: 10.5797/jnet.oa.2023-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/16/2023] [Indexed: 08/08/2023]
Abstract
Objective Intracranial atherosclerosis disease (ICAD) is one of the most common causes of acute ischemic stroke. In endovascular treatment (EVT) for acute large vessel occlusion stroke-related ICAD, reocclusion of the recanalized artery due to in situ thrombosis is problematic. In this study, the safety and efficacy of prasugrel administration to avoid reocclusion of emergent EVT for ICAD was investigated. Methods All consecutive emergent EVTs for ICAD between September 2019 and December 2022 were included in this study. The procedures were divided into two groups as receiving periprocedural prasugrel (PSG group) or not (non-PSG group). Target vessel patency on follow-up, postprocedural intracranial hemorrhage (ICH), and clinical outcome were compared between PSG and non-PSG groups. Results A total of 27 procedures were included in this analysis. Nineteen target vessels were patent on follow-up and eight were non-patent. Fifteen patients received prasugrel (18.75 mg: 11 cases, 11.25 mg: 4 cases), and twelve patients did not receive prasugrel. The target vessel patency rate was better in the PSG group vs. non-PSG group (100% vs. 33.3%, respectively; p = 0.0002). The postprocedural ICH rate was not different between the groups (PSG: 40.0% vs. non-PSG: 25.0%; p = 0.68), and all ICHs were asymptomatic. Good clinical outcome (modified Rankin Scale score of 0 to 3 at discharge) was more frequent in the PSG group than that in the non-PSG group (66.7% vs. 16.7%, respectively; p = 0.019). Conclusion Prasugrel administration was significantly associated with target vessel patency and good clinical outcome after emergent EVT for ICAD without increasing the symptomatic ICH rate. Prasugrel administration might be safe and effective to avoid reocclusion during and after emergent EVT for ICAD.
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Affiliation(s)
- Katsunori Asai
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Masaaki Taniguchi
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Akihiro Tateishi
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Naoki Irizato
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Hiroto Okubata
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Shogo Fukuya
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Kazuhiro Yoshimura
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Kazumi Yamamoto
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Akatsuki Wakayama
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
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27
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Huo X, Sun D, Chen W, Han H, Abdalkader M, Puetz V, Yi T, Wang H, Liu R, Tong X, Jia B, Ma N, Gao F, Mo D, Yan B, Mitchell PJ, Leung TW, Yavagal DR, Albers GW, Costalat V, Fiehler J, Zaidat OO, Jovin TG, Liebeskind DS, Nguyen TN, Miao Z. Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease. Semin Neurol 2023; 43:337-344. [PMID: 37549690 DOI: 10.1055/s-0043-1771207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Intracranial atherosclerotic disease (ICAD) is one of the most common causes of acute ischemic stroke worldwide. Patients with acute large vessel occlusion due to underlying ICAD (ICAD-LVO) often do not achieve successful recanalization when undergoing mechanical thrombectomy (MT) alone, requiring rescue treatment, including intra-arterial thrombolysis, balloon angioplasty, and stenting. Therefore, early detection of ICAD-LVO before the procedure is important to enable physicians to select the optimal treatment strategy for ICAD-LVO to improve clinical outcomes. Early diagnosis of ICAD-LVO is challenging in the absence of consensus diagnostic criteria on noninvasive imaging and early digital subtraction angiography. In this review, we summarize the clinical and diagnostic criteria, prediction of ICAD-LVO prior to the procedure, and EVT strategy of ICAD-LVO and provide recommendations according to the current literature.
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Affiliation(s)
- Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | | | - Volker Puetz
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hao Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Raynald Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre, Melbourne, Australia
| | - Peter J Mitchell
- Department of Radiology, Melbourne Brain Centre, Melbourne, Australia
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Dileep R Yavagal
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Güi-de-Chauliac, CHU de Montpellier, Montpellier, France
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Osama O Zaidat
- Department of Neuroscience, Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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28
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de Havenon A, Zaidat OO, Amin-Hanjani S, Nguyen TN, Bangad A, Abassi M, Anadani M, Almallouhi E, Chatterjee R, Mazighi M, Mistry E, Yaghi S, Derdeyn C, Hong KS, Kvernland A, Leslie-Mazwi T, Al Kasab S. Large Vessel Occlusion Stroke due to Intracranial Atherosclerotic Disease: Identification, Medical and Interventional Treatment, and Outcomes. Stroke 2023; 54:1695-1705. [PMID: 36938708 PMCID: PMC10202848 DOI: 10.1161/strokeaha.122.040008] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, SC
| | | | - Mikael Mazighi
- Neurology, Lariboisière hospital-APHP NORD, FHU Neurovasc, Paris Cité University, INSERM 1144, France
| | - Eva Mistry
- Neurology and Rehabilitation Medicine, University of Cincinnati, OH
| | - Shadi Yaghi
- Neurology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Colin Derdeyn
- Neurosurgery, Carver College of Medicine, Iowa City, Iowa
| | - Keun-Sik Hong
- Neurology, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | | | | | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, SC
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Alemseged F, Nguyen TN, Coutts SB, Cordonnier C, Schonewille WJ, Campbell BCV. Endovascular thrombectomy for basilar artery occlusion: translating research findings into clinical practice. Lancet Neurol 2023; 22:330-337. [PMID: 36780915 DOI: 10.1016/s1474-4422(22)00483-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/09/2022] [Accepted: 11/21/2022] [Indexed: 02/12/2023]
Abstract
BACKGROUND Basilar artery occlusion is a rare and severe condition. The effectiveness of endovascular thrombectomy in patients with basilar artery occlusion was unclear until recently, because these patients were excluded from most trials of endovascular thrombectomy for large-vessel occlusion ischaemic stroke. RECENT DEVELOPMENTS The Basilar Artery International Cooperation Study (BASICS) and the Basilar Artery Occlusion Endovascular Intervention versus Standard Medical Treatment (BEST) trials, specifically designed to investigate the benefit of thrombectomy in patients with basilar artery occlusion, did not find significant evidence of a benefit of endovascular thrombectomy in terms of disability outcomes at 3 months after stroke. However, these trials suggested a potential benefit of endovascular thrombectomy in patients presenting with moderate-to-severe symptoms. Subsequently, the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) and the Basilar Artery Occlusion Chinese Endovascular (BAOCHE) trials, which compared endovascular thrombectomy versus medical therapy within 24 h of onset, showed clear benefit of endovascular thrombectomy in reducing disability and mortality, particularly in patients with moderate-to-severe symptoms. The risk of intracranial haemorrhage with endovascular thrombectomy was similar to the risk in anterior circulation stroke. Thrombectomy was beneficial regardless of age, baseline characteristics, the presence of intracranial atherosclerotic disease, and time from symptom onset to randomisation. Therefore, the question of whether endovascular thrombectomy is beneficial in basilar artery occlusion now appears to be settled in patients with moderate-to-severe symptoms, and endovascular thrombectomy should be offered to eligible patients. WHERE NEXT?: Key outstanding issues are the potential benefits of endovascular thrombectomy in patients with mild symptoms, the use of intravenous thrombolysis in an extended time window (ie, after 4·5 h of symptom onset), and the optimal endovascular technique for thrombectomy. Dedicated training programmes and automated software to assist with the assessment of imaging prognostic markers could be useful in the selection of patients who might benefit from endovascular thrombectomy. Large international research networks should be built to address knowledge gaps in this field and allow the conduct of clinical trials with fast and consecutive enrolment and a diverse ethnic representation.
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Affiliation(s)
- Fana Alemseged
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Shelagh B Coutts
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Charlotte Cordonnier
- Université Lille, INSERM UMR-S1172, Centre Hospitalier Universitaire de Lille, Lille Neuroscience et Cognition, Lille, France
| | | | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia.
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Palaiodimou L, Eleftheriou A, Katsanos AH, Safouris A, Magoufis G, Spiliopoulos S, Velonakis G, Vassilopoulou S, de Sousa DA, Turc G, Strbian D, Tsivgoulis G. Endovascular Treatment for Acute Basilar Artery Occlusion: A Fragility Index Meta-Analysis. J Clin Med 2023; 12:jcm12072617. [PMID: 37048699 PMCID: PMC10094975 DOI: 10.3390/jcm12072617] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Introduction: High-quality evidence regarding the use of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) has been provided by recently completed randomized controlled clinical trials (RCTs). Methods: We conducted a systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of EVT in addition to best medical treatment (BMT) versus BMT alone for BAO. The random-effects model was used, while the fragility index (FI) was calculated for dichotomous outcomes of interest. Results: Four RCTs were included comprising a total of 988 patients with acute BAO (mean age: 65.6 years, 70% men, median NIHSS: 24, 39% pretreatment with intravenous thrombolysis). EVT was related to higher likelihood of good functional outcome (RR: 1.54; 95% CI: 1.16–2.05; I2 = 60%), functional independence (RR: 1.83; 95% CI: 1.08–3.08; I2 = 79%) and reduced disability at 3 months (adjusted common OR: 1.96; 95% CI: 1.26–3.05; I2 = 59%) compared to BMT alone. Despite that EVT was associated with a higher risk for symptomatic intracranial hemorrhage (RR: 7.78; 95% CI: 2.36–25.61; I2 = 0%) and any intracranial hemorrhage (RR: 2.85; 95% CI: 1.50–5.44; I2 = 16%), mortality at 3 months was lower among patients that received EVT plus BMT versus BMT alone (RR: 0.76; 95% CI: 0.65–0.89; I2 = 0%). However, sufficient robustness was not evident in any of the reported associations (FI < 10) including the overall effect regarding the primary outcome. The former associations were predominantly driven by RCTs with recruitment limited in China. Conclusions: EVT combined with BMT is associated with a higher likelihood of achieving good functional outcomes and a lower risk of death at 3 months compared to BMT alone, despite the higher risk of sICH. An individual-patient data meta-analysis is warranted to uncover and adjust for potential sources of heterogeneity and to provide further insight.
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Xu ZJ, Cao YZ, Zhao LB, Jia ZY, Lu SS, Xu XQ, Shi HB, Liu S. Effect of Truncal-Type Occlusion Based on Multiphase or Single-Phase Computed Tomographic Angiography in Predicting Intracranial Atherosclerotic Stenosis-Related Acute Middle Cerebral Artery Occlusion. J Comput Assist Tomogr 2023; Publish Ahead of Print:00004728-990000000-00134. [PMID: 37365699 DOI: 10.1097/rct.0000000000001447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVE To investigate whether truncal-type occlusion based on multiphase computed tomographic angiography (mpCTA) was more effective for predicting intracranial atherosclerotic stenosis-related occlusion (ICAS-O) than occlusion type based on single-phase computed tomographic angiography (spCTA) in patients with acute ischemic stroke with large-vessel occlusion (AIS-LVO) in the middle cerebral artery (MCA). METHODS Data were retrospectively collected from 72 patients with AIS-LVO in the MCA between January 2018 and December 2019. The occlusion types included truncal-type and branching-site occlusions. The association between ICAS-O and occlusion type based on the 2 computed tomographic angiography patterns was analyzed, and receiver operating characteristic curves were plotted for assessment. The areas under the curve were compared to determine the difference between the predictive powers of truncal-type occlusion based on mpCTA and spCTA. RESULTS Among the 72 patients, 16 were classified as having ICAS-O and 56 as having embolisms. In univariate analysis, truncal-type occlusion was significantly associated with ICAS-O (P < 0.001 for mpCTA and P = 0.001 for spCTA). After multivariable analysis, truncal-type occlusion based on both mpCTA and spCTA remained independently associated with ICAS-O (P = 0.002 for mpCTA and P = 0.029 for spCTA). The areas under the curve were 0.821 for mpCTA and 0.683 for spCTA; this difference was statistically significant (P = 0.024). CONCLUSIONS In patients with AIS-LVO in the MCA, truncal-type occlusion based on mpCTA enables more accurate detection of ICAS-O than that based on spCTA.
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Affiliation(s)
- Zhi-Jia Xu
- From the Department of Interventional Radiology; and
| | - Yue-Zhou Cao
- From the Department of Interventional Radiology; and
| | - Lin-Bo Zhao
- From the Department of Interventional Radiology; and
| | - Zhen-Yu Jia
- From the Department of Interventional Radiology; and
| | - Shan-Shan Lu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hai-Bin Shi
- From the Department of Interventional Radiology; and
| | - Sheng Liu
- From the Department of Interventional Radiology; and
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Rodrigo-Gisbert M, Requena M, Rubiera M, Khalife J, Lozano P, De Dios Lascuevas M, García-Tornel Á, Olivé-Gadea M, Piñana C, Rizzo F, Boned S, Muchada M, Rodríguez-Villatoro N, Rodríguez-Luna D, Juega J, Pagola J, Hernández D, Molina CA, Tomasello A, Ribo M. Intracranial Artery Calcifications Profile as a Predictor of Recanalization Failure in Endovascular Stroke Treatment. Stroke 2023; 54:430-438. [PMID: 36689597 DOI: 10.1161/strokeaha.122.041257] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Acute ischemic stroke with large or medium-vessel occlusion associated with intracranial artery calcification (IAC) is an infrequent phenomenon presumably associated with intracranial atherosclerotic disease. We aimed to characterize IAC and its impact on endovascular treatment outcomes. METHODS We performed a retrospective cross-sectional study of consecutive patients with stroke treated with thrombectomy from January 2020 to July 2021 in our institution. We described IAC findings (length, density, and location pattern) on baseline noncontrast computed tomography. Patients were divided into 3 groups: IAC related to the occlusion location (symptomatic-IAC group), unrelated to the occlusion (asymptomatic-IAC group), and absence of any IAC (non-IAC group). We analyzed the association between the IAC profile and outcomes using logistic regression models. Intracranial angioplasty and stenting were considered rescue treatments. RESULTS Of the 393 patients included, 26 (6.6%) patients presented a symptomatic-IAC, 77 (19.6%) patients an asymptomatic-IAC, and in 290 (73.8%) patients no IAC was observed. The rate of failed recanalization (expanded Thrombolysis in Cerebral Infarction 0-2a) before rescue treatment was higher in symptomatic-IAC (65.4%) than in asymptomatic-IAC (15.6%; P<0.001) or non-IAC (13.4%; P<0.001). Rescue procedures were more frequently performed in symptomatic-IAC (26.9%) than in asymptomatic-IAC (1.3%; P<0.001) and non-IAC (4.1%; P<0.001). After adjusting for identifiable clinical and radiological confounders, symptomatic-IAC emerged as an independent predictor of failed recanalization (odds ratio, 11.89 [95% CI, 3.94-35.91]; P<0.001), adoption of rescue procedures (odds ratio, 12.38 [95% CI, 2.22-69.09]; P=0.004), and poor functional outcome (90-day modified Rankin Scale score ≥3; odds ratio, 3.51 [95% CI, 1.02-12.00]; P=0.046). CONCLUSIONS The presence of IAC related to the occlusion location is associated with worse angiographic and functional outcomes. Therefore, identification of symptomatic-IAC on baseline imaging may guide optimal endovascular treatment strategy, predicting the need for intracranial stenting and angioplasty.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ (J.K.)
| | - Prudencio Lozano
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta De Dios Lascuevas
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Carlos Piñana
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (C.P., D.H.)
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Sandra Boned
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - David Rodríguez-Luna
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jesús Juega
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - David Hernández
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (C.P., D.H.)
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Alejandro Tomasello
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
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Li K, Sun D, Tong X, Wang A, Zhang Y, Ma G, Huo X, Ma N, Gao F, Mo D, Sun X, Peng G, Zhang X, Jia B, Miao Z. Incidence, predictors, and impact on outcome of underlying intracranial atherosclerotic disease in acute vertebrobasilar artery occlusion undergoing endovascular therapy: Data from ANGEL-ACT registry. Int J Stroke 2023:17474930221150111. [PMID: 36571164 DOI: 10.1177/17474930221150111] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial atherosclerotic disease (ICAD) is a common etiology of acute vertebrobasilar artery occlusion (VBAO) in Asia, which complicated endovascular treatment (EVT). We aimed to investigate the incidence, impacts, and predictors of ICAD in VBAO. METHODS Subjects were selected from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke registry and divided into two groups based on whether underlying ICAD existed. Underlying ICAD was determined when the following situations arise in the occlusion site during EVT: (1) fixed stenosis degree >70% or (2) stenosis >50% with distal blood flow impairment or evidence of repeated reocclusion. Multivariable regression models were used to investigate the effect of underlying ICAD on outcomes measured by modified Rankin Scale (mRS) score at 90 days and to identify baseline characteristics associated with underlying ICAD. RESULTS Among the 315 patients enrolled, 171 (54.3%) had underlying ICAD. Favorable functional outcomes (mRS 0-3) occurred in 79 of 163 patients (48.5%) with ICAD and 69 of 137 patients (50.4%) without ICAD (p = 0.743). Outcomes were similar between the two groups and remained similar after adjusting for the confounders. History of hypertension and elevated admission neutrophil to lymphocyte ratio were strong predictors of underlying ICAD, whereas history of atrial fibrillation and distal basilar artery occlusion were negative predictors. CONCLUSIONS In our study, underlying ICAD was recognized in approximately half of the VBAO patients, leading to comparable outcomes after more complex EVT strategies. Some baseline characteristics were identified to be predictors for underlying ICAD, which were helpful to guide the EVT strategies before the procedure.
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Affiliation(s)
- Kangyue Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yijun Zhang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangge Peng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xuelei Zhang
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Abdalkader M, Siegler JE, Lee JS, Yaghi S, Qiu Z, Huo X, Miao Z, Campbell BC, Nguyen TN. Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy. J Stroke 2023; 25:55-71. [PMID: 36746380 PMCID: PMC9911849 DOI: 10.5853/jos.2022.03286] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians' preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.
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Affiliation(s)
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
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35
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Perceptions on basilar artery occlusion management in China versus other countries: Analysis of the after the BEST of BASICS (ABBA) survey. J Stroke Cerebrovasc Dis 2022; 31:106804. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/23/2022] Open
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36
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Lu Y, Shen R, Lin W, Zhou X, Hu J, Zhang Q. Association between blood pressure variability and clinical outcomes after successful recanalization in patients with large vessel occlusion stroke after mechanical thrombectomy. Front Neurol 2022; 13:967395. [PMID: 36034274 PMCID: PMC9399916 DOI: 10.3389/fneur.2022.967395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Nearly half of patients who undergo mechanical thrombectomy (MT) do not experience a favorable outcome. The association between blood pressure fluctuation and clinical outcomes after successful MT is controversial. We evaluated the influence of blood pressure variability (BPV) on the clinical outcomes of stroke patients with large vessel occlusion (LVO) who underwent successful recanalization after MT. Methods Patients with anterior circulation LVO stroke who underwent successful emergency MT (modified Thrombolysis in Cerebral Infarction, mTICI ≥ 2b) at the Shanghai Tenth People's Hospital of Tongji University from 2017 to 2021 were enrolled. Multivariate logistic models were used to investigate the association between BPV (mean arterial pressure [MAP] assessed using the standard deviation [SD]) and clinical outcomes. The primary outcome was 90-day modified Rankin Scale scores (mRS), and the secondary outcomes were 30-day mortality and symptomatic intracranial hemorrhage (sICH). Results A total of 458 patients (56.8% men), with a mean age of 72 ± 1 years, were enrolled. Among them, 207 (45.2%) patients had unfavorable functional outcomes (mRS score 3–6) at 90 days, 61 (13.3%) patients died within 30 days, and 20 (4.4%) patients had sICH. In a fully adjusted model, BPV was associated with a higher risk of a 90-day mRS score of 3–6 (P = 0.04), 30-day mortality (P < 0.01), and sICH (P < 0.01). A significant interaction between MAP SD and rescue futile recanalization treatment was observed (P < 0.01). Conclusions Among patients with LVO stroke who underwent successful recanalization, higher BPV was associated with worse functional outcomes, especially in those who underwent rescue treatment.
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Affiliation(s)
- You Lu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Shen
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenjian Lin
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoyu Zhou
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Hu
- Department of Radiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- Jian Hu
| | - Quanbin Zhang
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Quanbin Zhang
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Kim BJ, Menon BK, Yoo J, Han JH, Kim BJ, Kim CK, Kim JG, Kim JT, Park H, Baik SH, Han MK, Kang J, Kim JY, Lee KJ, Park JM, Kang K, Lee SJ, Cha JK, Kim DH, Jeong JH, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi KH, Choi JC, Kim JG, Kwon JH, Kim WJ, Shin DI, Yum KS, Sohn SI, Hong JH, Kim C, Lee SH, Lee J, Almekhlafi MA, Demchuk A, Bae HJ. Effectiveness and safety of EVT in patients with acute LVO and low NIHSS. Front Neurol 2022; 13:955725. [PMID: 35989920 PMCID: PMC9389111 DOI: 10.3389/fneur.2022.955725] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purpose There is much uncertainty in endovascular treatment (EVT) decisions in patients with acute large vessel occlusion (LVO) and mild neurological deficits. Methods From a prospective, nationwide stroke registry, all patients with LVO and baseline NIHSS <6 presenting within 24 h from the time last known well (LKW) were included. Early neurological deterioration (END) developed before EVT was prospectively collected as an increasing total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores during hospitalization not related to EVT. Significant hemorrhage was defined as PH2 hemorrhagic transformation or hemorrhage at a remote site. The modified Rankin Scale (mRS) was prospectively collected at 3 months. Results Among 1,083 patients, 149 (14%) patients received EVT after a median of 5.9 [3.6-12.3] h after LKW. In propensity score-matched analyses, EVT was not associated with mRS 0-1 (matched OR 0.99 [0.63-1.54]) but increased the risk of a significant hemorrhage (matched OR, 4.51 [1.59-12.80]). Extraneous END occurred in 207 (19%) patients after a median of 24.5 h [IQR, 13.5-41.9 h] after LKW (incidence rate, 1.41 [95% CI, 1.23-1.62] per 100 person-hours). END unrelated to EVT showed a tendency to modify the effectiveness of EVT (P-for-interaction, 0.08), which decreased the odds of having mRS 0-1 in mild LVO patients without END (adjusted OR, 0.63 [0.40-0.99]). Conclusions The use of EVT in patients with acute LVO and low NIHSS scores may require the assessment of individual risks of early deterioration, hemorrhagic complications and expected benefit.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Bijoy K. Menon
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yongin-si, South Korea
| | - Jung Hoon Han
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jihoon Kang
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Keon-Joo Lee
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si, South Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, South Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Jin-Heon Jeong
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, South Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, South Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Joong-Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Chulho Kim
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, South Korea
| | - Sang-Hwa Lee
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, South Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University, Seoul, South Korea
| | - Mohammed A. Almekhlafi
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Andrew Demchuk
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
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Lee SJ, Hong JM, Kim JS, Lee JS. Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy. J Stroke 2022; 24:207-223. [PMID: 35677976 PMCID: PMC9194547 DOI: 10.5853/jos.2022.00941] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022] Open
Abstract
The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
- Correspondence: Jin Soo Lee Department of Neurology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5175 Fax: +82-31-219-5178 E-mail:
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39
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Kim JS. Endovascular Thrombectomy in Patients with Intracranial Atherosclerosis: Where Are We? J Stroke 2022; 24:1-2. [PMID: 35135055 PMCID: PMC8829484 DOI: 10.5853/jos.2022.00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jong S. Kim
- Stroke Center and Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence: Jong S. Kim Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3442 Fax: +82-2-474-4691 E-mail:
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