1
|
Zhou M, Stobbe R, Szczepankiewicz F, Budde M, Buck B, Kate M, Lloret M, Fairall P, Butcher K, Shuaib A, Emery D, Nilsson M, Westin CF, Beaulieu C. Tensor-valued diffusion MRI of human acute stroke. Magn Reson Med 2024; 91:2126-2141. [PMID: 38156813 DOI: 10.1002/mrm.29975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/18/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Tensor-valued diffusion encoding can disentangle orientation dispersion and subvoxel anisotropy, potentially offering insight into microstructural changes after cerebral ischemia. The purpose was to evaluate tensor-valued diffusion MRI in human acute ischemic stroke, assess potential confounders from diffusion time dependencies, and compare to Monte Carlo diffusion simulations of axon beading. METHODS Linear (LTE) and spherical (STE) b-tensor encoding with inherently different effective diffusion times were acquired in 21 acute ischemic stroke patients between 3 and 57 h post-onset at 3 T in 2.5 min. In an additional 10 patients, STE with 2 LTE yielding different effective diffusion times were acquired for comparison. Diffusional variance decomposition (DIVIDE) was used to estimate microscopic anisotropy (μFA), as well as anisotropic, isotropic, and total diffusional variance (MKA , MKI , MKT ). DIVIDE parameters, and diffusion tensor imaging (DTI)-derived mean diffusivity and fractional anisotropy (FA) were compared in lesion versus contralateral white matter. Monte Carlo diffusion simulations of various cylindrical geometries for all b-tensor protocols were used to interpret parameter measurements. RESULTS MD was ˜40% lower in lesions for all LTE/STE protocols. The DIVIDE parameters varied with effective diffusion time: higher μFA and MKA in lesion versus contralateral white matter for STE with longer effective diffusion time LTE, whereas the shorter effective diffusion time LTE protocol yielded lower μFA and MKA in lesions. Both protocols, regardless of diffusion time, were consistent with simulations of greater beading amplitude and intracellular volume fraction. CONCLUSION DIVIDE parameters depend on diffusion time in acute stroke but consistently indicate neurite beading and larger intracellular volume fraction.
Collapse
Affiliation(s)
- Mi Zhou
- Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Stobbe
- Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
- Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | | | - Matthew Budde
- Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Brian Buck
- Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Mahesh Kate
- Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Mar Lloret
- Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Paige Fairall
- Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Ken Butcher
- School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Ashfaq Shuaib
- Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Derek Emery
- Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Markus Nilsson
- Clinical Sciences Lund, Lund University, Lund, Scania, Sweden
| | - Carl-Fredrik Westin
- Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian Beaulieu
- Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
- Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
2
|
Singh N, Kenney C, Butcher K, Buck B, Barber PA, Field TS, Choi P, Yu AYX, Kleinig T, Appireddy R, Molina CA, Muir KW, Hill MD, Coutts SB. A Randomized Controlled Trial of Tenecteplase Versus Standard of Care for Minor Ischemic Stroke With Proven Occlusion (TEMPO-2): Rational and design of a multicenter, randomized open-label clinical trial. Int J Stroke 2024:17474930241253702. [PMID: 38676572 DOI: 10.1177/17474930241253702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
BACKGROUND Almost half of acute ischemic stroke patients present with mild symptoms and there are large practice variations in their treatment globally. Individuals with an intracranial occlusion who present with minor stroke are at an increased risk of early neurological deterioration and poor outcomes. Individual patient data meta-analysis in the subgroup of patients with minor deficits showed benefit of alteplase in improving outcomes, however, this benefit has not been seen with intravenous alteplase in published randomized trials. DESIGN TEMPO-2 (A Randomized Controlled Trial of tenecteplase Versus Standard of Care for Minor Ischemic Stroke With Proven Occlusion) is a prospective, open label with blinded outcome assessment, randomized controlled trial, designed to test the superiority of intravenous tenecteplase (0.25mg/kg) over non thrombolytic standard of care, with an estimated sample size of 1274 patients. Adult patients presenting with acute ischemic stroke with NIHSS <5 and visible arterial occlusion or perfusion deficit within 12 hours of onset are randomized to receive either tenecteplase (0.25 mg/kg) or standard of care. The primary outcome is return to baseline neurological functioning, measured by the modified Rankin Scale (mRS) at 90 days. Safety outcomes include death and symptomatic hemorrhage (intra or extra-cranial). Other secondary outcomes include mRS 0-1, mRS 0-2, ordinal shift analysis of the mRS, partial and full recanalization on follow up CT Angiogram. CONCLUSION Results of this trial will aid in determining whether there is benefit of using tenecteplase (0.25mg/kg) in treating patients presenting with minor stroke who are at high risk of developing poor outcomes due to presence of an intracranial occlusion. TRIAL REGISTRY NAME A Randomized Controlled Trial of tenecteplase Versus Standard of Care for Minor Ischemic Stroke With Proven Occlusion, Registration number: NCT02398656; URL: https://clinicaltrials.gov/study/NCT02398656.
Collapse
Affiliation(s)
- Nishita Singh
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Carol Kenney
- University of Calgary, Department of Neurosciences, Radiology and Community Health Sciences, Calgary, Canada
| | - Kenneth Butcher
- School of Clinical Medicine, University of New South Wales, Australia
| | - Brian Buck
- University of Alberta, Division of Neurology, Department of Medicine, Edmonton, Canada
| | - Philip A Barber
- University of Calgary, Department of Neurosciences, Radiology and Community Health Sciences, Calgary, Canada
| | - Thalia Shoshana Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Philip Choi
- Department of Neurosciences, Box Hill Hospital, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Amy Ying Xin Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, ON, Canada
| | - Tim Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Keith W Muir
- School of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Michael D Hill
- University of Calgary, Department of Neurosciences, Radiology and Community Health Sciences, Calgary, Canada
- Department of Community Health Sciences, Cumming School of Medicine Calgary, Canada
- Department of Medicine, Department of Radiology, Cumming School of Medicine
| | - Shelagh B Coutts
- University of Calgary, Department of Neurosciences, Radiology and Community Health Sciences, Calgary, Canada
- Department of Community Health Sciences, Cumming School of Medicine Calgary, Canada
| |
Collapse
|
3
|
Soltanpour M, Boulanger P, Buck B. CT Perfusion Map Synthesis from CTP Dynamic Images Using a Learned LSTM Generative Adversarial Network for Acute Ischemic Stroke Assessment. J Med Syst 2024; 48:37. [PMID: 38564061 DOI: 10.1007/s10916-024-02054-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
Computed tomography perfusion (CTP) is a dynamic 4-dimensional imaging technique (3-dimensional volumes captured over approximately 1 min) in which cerebral blood flow is quantified by tracking the passage of a bolus of intravenous contrast with serial imaging of the brain. To diagnose and assess acute ischemic stroke, the standard method relies on summarizing acquired CTPs over the time axis to create maps that show different hemodynamic parameters, such as the timing of the bolus arrival and passage (Tmax and MTT), cerebral blood flow (CBF), and cerebral blood volume (CBV). However, producing accurate CTP maps requires the selection of an arterial input function (AIF), i.e. a time-concentration curve in one of the large feeding arteries of the brain, which is a highly error-prone procedure. Moreover, during approximately one minute of CT scanning, the brain is exposed to ionizing radiation that can alter tissue composition, and create free radicals that increase the risk of cancer. This paper proposes a novel end-to-end deep neural network that synthesizes CTP images to generate CTP maps using a learned LSTM Generative Adversarial Network (LSTM-GAN). Our proposed method can improve the precision and generalizability of CTP map extraction by eliminating the error-prone and expert-dependent AIF selection step. Further, our LSTM-GAN does not require the entire CTP time series and can produce CTP maps with a reduced number of time points. By reducing the scanning sequence from about 40 to 9 time points, the proposed method has the potential to minimize scanning time thereby reducing patient exposure to CT radiation. Our evaluations using the ISLES 2018 challenge dataset consisting of 63 patients showed that our model can generate CTP maps by using only 9 snapshots, without AIF selection, with an accuracy of 84.37 % .
Collapse
Affiliation(s)
- Mohsen Soltanpour
- Computing Science Department, University of Alberta, Edmonton, Canada.
| | - Pierre Boulanger
- Computing Science Department, University of Alberta, Edmonton, Canada
| | - Brian Buck
- Medicine Deptment, University of Alberta, Edmonton, Canada
| |
Collapse
|
4
|
Doyle TJ, Gumke M, Stanek D, Moore J, Buck B, Locksmith T, Tomson K, Schmedes S, Churchwell G, Hubsmith SJ, Krishnamoorthy B, Poschman K, Danforth B, Chacreton D. Concurrent Outbreaks of Hepatitis A, Invasive Meningococcal Disease, and Mpox, Florida, USA, 2021-2022. Emerg Infect Dis 2024; 30. [PMID: 38526187 PMCID: PMC10977815 DOI: 10.3201/eid3004.231392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
In 2022, concurrent outbreaks of hepatitis A, invasive meningococcal disease (IMD), and mpox were identified in Florida, USA, primarily among men who have sex with men. The hepatitis A outbreak (153 cases) was associated with hepatitis A virus genotype IA. The IMD outbreak (44 cases) was associated with Neisseria meningitidis serogroup C, sequence type 11, clonal complex 11. The mpox outbreak in Florida (2,845 cases) was part of a global epidemic. The hepatitis A and IMD outbreaks were concentrated in Central Florida and peaked during March--June, whereas mpox cases were more heavily concentrated in South Florida and had peak incidence in August. HIV infection was more common (52%) among mpox cases than among hepatitis A (21%) or IMD (34%) cases. Where feasible, vaccination against hepatitis A, meningococcal disease, and mpox should be encouraged among at-risk groups and offered along with program services that target those groups.
Collapse
|
5
|
Ospel JM, Rex N, Rinkel L, Kashani N, Buck B, Rempel J, Sahlas D, Kelly ME, Budzik R, Tymianski M, Hill MD, Goyal M. Prevalence of "Ghost Infarct Core" after Endovascular Thrombectomy. AJNR Am J Neuroradiol 2024; 45:291-295. [PMID: 38272571 DOI: 10.3174/ajnr.a8113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 12/01/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND AND PURPOSE Baseline CTP sometimes overestimates the size of the infarct core ("ghost core" phenomenon). We investigated how often CTP overestimates infarct core compared with 24-hour imaging, and aimed to characterize the patient subgroup in whom a ghost core is most likely to occur. MATERIALS AND METHODS Data are from the randomized controlled ESCAPE-NA1 trial, in which patients with acute ischemic stroke undergoing endovascular treatment were randomized to intravenous nerinetide or placebo. Patients with available baseline CTP and 24-hour follow-up imaging were included in the analysis. Ghost infarct core was defined as CTP core volume minus 24-hour infarct volume > 10 mL). Clinical characteristics of patients with versus without ghost core were compared. Associations of ghost core and clinical characteristics were assessed by using multivariable logistic regression. RESULTS A total of 421 of 1105 patients (38.1%) were included in the analysis. Forty-seven (11.2%) had a ghost core > 10 mL, with a median ghost infarct volume of 13.4 mL (interquartile range 7.6-26.8). Young patient age, complete recanalization, short last known well to CT times, and possibly male sex were associated with ghost infarct core. CONCLUSIONS CTP ghost core occurred in ∼1 of 10 patients, indicating that CTP frequently overestimates the infarct core size at baseline, particularly in young patients with complete recanalization and short ischemia duration.
Collapse
Affiliation(s)
- Johanna M Ospel
- From the Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., N.R., L.R., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - Nathaniel Rex
- Department of Clinical Neurosciences (J.M.O., N.R., L.R., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Diagnostic Imaging (N.R.), Brown University, Providence, Rhode Island
| | - Leon Rinkel
- Department of Clinical Neurosciences (J.M.O., N.R., L.R., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Neurology (L.R.), Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Nima Kashani
- Department of Neurosurgery (N.K., M.E.K.), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brian Buck
- University of Alberta Hospital (B.B., J.R.), Edmonton, Alberta, Canada
| | - Jeremy Rempel
- University of Alberta Hospital (B.B., J.R.), Edmonton, Alberta, Canada
| | | | - Michael E Kelly
- Department of Neurosurgery (N.K., M.E.K.), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ron Budzik
- Ohio Health (R.B.), Riverside Methodist Hospital, Columbus, Ohio
| | | | - Michael D Hill
- From the Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., N.R., L.R., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- From the Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., N.R., L.R., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
6
|
Weller J, Krzywicka K, van de Munckhof A, Dorn F, Althaus K, Bode FJ, Bandettini di Poggio M, Buck B, Kleinig T, Cordonnier C, Dizonno V, Duan J, Elkady A, Chew BLA, Garcia-Esperon C, Field TS, Legault C, Morin Martin M, Michalski D, Pelz J, Schoenenberger S, Nagel S, Petruzzellis M, Raposo N, Skjelland M, Zimatore DS, Aaron S, Sanchez van Kammen M, Aguiar de Sousa D, Lindgren E, Jood K, Scutelnic A, Heldner MR, Poli S, Arauz A, Conforto AB, Putaala J, Tatlisumak T, Arnold M, Coutinho JM, Günther A, Zimmermann J, Ferro JM. Endovascular treatment of cerebral sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia. Eur Stroke J 2024; 9:105-113. [PMID: 37771138 PMCID: PMC10916823 DOI: 10.1177/23969873231202363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/03/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION There is little data on the role of endovascular treatment (EVT) of cerebral venous sinus thrombosis (CVST) due to vaccine-induced immune thrombotic thrombocytopenia (VITT). Here, we describe clinical characteristics and outcomes of CVST-VITT patients who were treated with EVT. PATIENTS AND METHODS We report data from an international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 6 March 2023. VITT was defined according to the Pavord criteria. RESULTS EVT was performed in 18/136 (13%) patients with CVST-VITT (92% aspiration and/or stent retrieval, 8% local thrombolysis). Most common indications were extensive thrombosis and clinical or radiological deterioration. Compared to non-EVT patients, those receiving EVT had a higher median thrombus load (4.5 vs 3). Following EVT, local blood flow was improved in 83% (10/12, 95% confidence interval [CI] 54-96). One (6%) asymptomatic sinus perforation occurred. Eight (44%) patients treated with EVT also underwent decompressive surgery. Mortality was 50% (9/18, 95% CI 29-71) and 88% (8/9, 95% CI 25-66) of surviving EVT patients achieved functional independence with a modified Rankin Scale score of 0-2 at follow-up. In multivariable analysis, EVT was not associated with increased mortality (adjusted odds ratio, 0.66, 95% CI 0.16-2.58). DISCUSSION AND CONCLUSION We describe the largest cohort of CVST-VITT patients receiving EVT. Half of the patients receiving EVT died during hospital admission, but most survivors achieved functional independence.
Collapse
Affiliation(s)
- Johannes Weller
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | | | - Felix J Bode
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | | | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, AB, Canada
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, Lille, France
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jiangang Duan
- Department of Neurology and Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia
| | | | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Catherine Legault
- Division of Neurology, McGill University Health Centre, Montreal, QC, Canada
| | - Mar Morin Martin
- Department of Neurology, Hospital Complex of Toledo, Toledo, Spain
| | | | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Marco Petruzzellis
- Neuroradiology Unit, Azienda Ospedaliera Consorziale Policlinico di Bari, Italy
| | - Nicolas Raposo
- Department of Neurology, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France and Inserm, Toulouse NeuroImaging Center, Université de Toulouse, Toulouse, France
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Sanjith Aaron
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mayte Sanchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Stroke Centre, Lisbon Central University Hospital, Lisbon, Portugal
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
| | - Adriana B Conforto
- Hospital das Clinicas/São Paulo University and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - José M Ferro
- Centro de Estudas Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal
| |
Collapse
|
7
|
Okusanya D, Ezeugwa JC, Khan A, Buck B, Jickling GC, Ezeugwu VE. The whole day matters after stroke: Study protocol for a randomized controlled trial investigating the effect of a 'sit less, move more, sleep better' program early after stroke. PLoS One 2023; 18:e0290515. [PMID: 38060584 PMCID: PMC10703225 DOI: 10.1371/journal.pone.0290515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Movement-related behaviours, including prolonged sedentary behaviour, physical inactivity, and poor sleep, are associated with worse functional outcomes poststroke. Addressing these co-dependent behaviours early after stroke may help to optimize recovery and improve overall quality of life for individuals with stroke. OBJECTIVE This study aims to determine the feasibility and effect of a 'sit less, move more, sleep better' program early after stroke on functional mobility and global disability outcomes, while also exploring imaging and behavioural markers that may influence walking recovery. METHODS The study is an assessor-blinded, single-center, parallel-group, randomized controlled trial to be completed within 24 months from July 12, 2023 to June 30, 2025. We will enroll 50 patients with acute ischemic stroke within 7 days from symptom onset, aged 18 years or older, and with ongoing walking goals. Demographic and stroke characteristics, including stroke risk factors, neuroimaging, and acute stroke treatments, will be determined and documented. All participants will wear an accelerometer for one week at three different time-points (baseline, 6, and 12 weeks) to assess movement-related behaviours. Following randomization, participants in the intervention arm will receive a 'sit less, move more, sleep better' program for up to 1 hour/day, 5 days/week, for 6 weeks to enhance self-efficacy for change. Participants in the control arm will receive usual inpatient and early supported stroke discharge care. The feasibility outcomes will include reach (enrolled/eligible), retention (completed/enrolled), adverse events, and program adherence. Other outcomes at 6 and 12 weeks include the modified Rankin Scale, Timed-Up and Go, movement-related behaviours, walking endurance, gait speed, cognition, stroke severity and quality of life. Mixed-effects models will assess changes in outcomes over time. Compositional associations between movement-related behaviours and outcomes will consider covariates such as imaging markers. DISCUSSION Adopting a whole-day approach to poststroke rehabilitation will provide valuable insights into the relationship between optimizing movement-related behaviours early after stroke and their impact on functional outcomes. Through exploring person-specific behavioural and imaging markers, this study may inform precision rehabilitation strategies, and guide clinical decision making for more tailored interventions. TRIAL REGISTRATION Clinical Trial registration (ClinicalTrials.gov Identifier: NCT05753761, March 3, 2023).
Collapse
Affiliation(s)
- Deborah Okusanya
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Joy C. Ezeugwa
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Aiza Khan
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Brian Buck
- Faculty of Medicine and Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Glen C. Jickling
- Faculty of Medicine and Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Victor E. Ezeugwu
- Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
8
|
Singh N, Almekhlafi MA, Bala F, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Buck B, Appireddy R, Moreau F, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JJ, Ghrooda E, Poppe AY, Williams H, Field TS, Manosalva A, Siddiqui MM, Zafar A, Imoukhoude O, Hunter G, Shamy M, Demchuk AM, Claggett BL, Hill MD, Sajobi TT, Swartz RH, Menon BK. Effect of Time to Thrombolysis on Clinical Outcomes in Patients With Acute Ischemic Stroke Treated With Tenecteplase Compared to Alteplase: Analysis From the AcT Randomized Controlled Trial. Stroke 2023; 54:2766-2775. [PMID: 37800372 DOI: 10.1161/strokeaha.123.044267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/23/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND The AcT (Alteplase Compared to Tenecteplase) randomized controlled trial showed that tenecteplase is noninferior to alteplase in treating patients with acute ischemic stroke within 4.5 hours of symptom onset. The effect of time to treatment on clinical outcomes with alteplase is well known; however, the nature of this relationship is yet to be described with tenecteplase. We assessed whether the association of time to thrombolysis treatment with clinical outcomes in patients with acute ischemic stroke differs by whether they receive intravenous tenecteplase versus alteplase. METHODS Patients included were from AcT, a pragmatic, registry-linked, phase 3 randomized controlled trial comparing intravenous tenecteplase to alteplase in patients with acute ischemic stroke. Eligible patients were >18 years old, with disabling neurological deficits, presenting within 4.5 hours of symptom onset, and eligible for thrombolysis. Primary outcome was modified Rankin Scale score 0 to 1 at 90 days. Safety outcomes included 24-hour symptomatic intracerebral hemorrhage and 90-day mortality rates. Mixed-effects logistic regression was used to assess the following: (a) the association of stroke symptom onset to needle time; (b) door (hospital arrival) to needle time with outcomes; and (c) if these associations were modified by type of thrombolytic administered (tenecteplase versus alteplase), after adjusting for age, sex, baseline stroke severity, and site of intracranial occlusion. RESULTS Of the 1538 patients included in this analysis, 1146 (74.5%; 591 tenecteplase and 555 alteplase) presented within 3 hours versus 392 (25.5%; 196: TNK and 196 alteplase) who presented within 3 to 4.5 hours of symptom onset. Baseline patient characteristics in the 0 to 3 hours versus 3- to 4.5-hour time window were similar, except patients in the 3- to 4.5-hour window had lower median baseline National Institutes of Health Stroke Severity Scale (10 versus 7, respectively) and lower proportion of patients with large vessel occlusion on baseline CT angiography (26.9% versus 18.7%, respectively). Type of thrombolytic agent (tenecteplase versus alteplase) did not modify the association between continuous onset to needle time (Pinteraction=0.161) or door-to-needle time (Pinteraction=0.972) and primary clinical outcome. Irrespective of the thrombolytic agent used, each 30-minute reduction in onset to needle time was associated with a 1.8% increase while every 10 minutes reduction in door-to-needle time was associated with a 0.2% increase in the probability of achieving 90-day modified Rankin Scale score 0 to 1, respectively. CONCLUSIONS The effect of time to tenecteplase administration on clinical outcomes is like that of alteplase, with faster administration resulting in better clinical outcomes. REGISTRATION URL: https://classic. CLINICALTRIALS gov; Unique identifier: NCT03889249.
Collapse
Affiliation(s)
- Nishita Singh
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada (N.S., E.G.)
| | - Mohammed A Almekhlafi
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Fouzi Bala
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
- Diagnostic and Interventional Neuroradiology, Tours University Hospital, France (F.B.)
| | - Ayoola Ademola
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
| | - Shelagh B Coutts
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Yan Deschaintre
- Department of Clinical Neurosciences, Université de Montréal, Canada (Y.D., A.Y.P.)
| | - Houman Khosravani
- Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada (H.K., R.H.S.)
| | - Brian Buck
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada (B.B.)
| | - Ramana Appireddy
- Department of Medicine, Division of Neurology, Queen's University, Kingston, ON, Canada (R.A.)
| | - Francois Moreau
- Department of Internal Medicine, Université de Sherbrooke, QC, Canada (F.M.)
| | - Gord Gubitz
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.G.)
| | - Aleksander Tkach
- Department of Neurosciences, Kelowna General Hospital, Canada (A.T.)
| | - Luciana Catanese
- Department of Medicine, McMaster University, Hamilton, Canada (L.C.)
| | - Dar Dowlatshahi
- Department of Medicine, and Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., M.S.)
| | - George Medvedev
- Department of Neurosciences, University of British Columbia, Vancouver, Canada (G.M., T.S.F.)
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | - Aleksandra Pikula
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | - Jai Jai Shankar
- Department of Radiology, Health Sciences Center, University of Manitoba, Winnipeg, Canada (J.J.S.)
| | - Esseeddeegg Ghrooda
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada (N.S., E.G.)
| | - Alexandre Y Poppe
- Department of Clinical Neurosciences, Université de Montréal, Canada (Y.D., A.Y.P.)
| | - Heather Williams
- Department of Medicine, Queen Elizabeth Health Sciences Centre, Charlottetown, Canada (H.W.)
| | - Thalia S Field
- Department of Neurosciences, University of British Columbia, Vancouver, Canada (G.M., T.S.F.)
| | - Alejandro Manosalva
- Department of Medicine, Medicine Hat Regional Hospital, Calgary, Canada (A.M.)
| | | | - Atif Zafar
- St Michael's Hospital, Toronto, ON, Canada (A.Z.)
| | - Oje Imoukhoude
- Department of Medicine, Red Deer Regional Hospital, Calgary, Canada (O.I.)
| | - Gary Hunter
- Department of Medicine, University of Saskatoon, Canada (G.H.)
| | - Michel Shamy
- Department of Medicine, and Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., M.S.)
| | - Andrew M Demchuk
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
| | - Brian L Claggett
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA (B.L.C.)
| | - Michael D Hill
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| | - Tolulope T Sajobi
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
| | - Richard H Swartz
- Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, Canada (H.K., R.H.S.)
| | - Bijoy K Menon
- Department of Neurosciences, Radiology and Community Health Sciences, University of Calgary, Canada (N.S., M.A.A., A.A., S.B.C., A.M.D., M.D.H., T.T.S., B.K.M.)
- Department of Community Health Sciences, University of Calgary, Canada (M.A.A., A.A., S.B.C., M.D.H., T.T.S., B.K.M.)
- Department of Radiology, University of Calgary, Canada (M.A.A., F.B., S.B.C., M.D.H., B.K.M.)
| |
Collapse
|
9
|
Bala F, Singh N, Buck B, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Appireddy R, Moreau F, Phillips S, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JJ, Williams H, Field TS, Manosalva Alzate A, Siddiqui M, Zafar A, Imoukhoude O, Hunter G, Alhabli I, Benali F, Horn M, Hill MD, Shamy M, Sajobi TT, Swartz RH, Menon BK, Almekhlafi M. Safety and Efficacy of Tenecteplase Compared With Alteplase in Patients With Large Vessel Occlusion Stroke: A Prespecified Secondary Analysis of the ACT Randomized Clinical Trial. JAMA Neurol 2023; 80:824-832. [PMID: 37428494 PMCID: PMC10334294 DOI: 10.1001/jamaneurol.2023.2094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/28/2023] [Indexed: 07/11/2023]
Abstract
Importance It is unknown whether intravenous thrombolysis using tenecteplase is noninferior or preferable compared with alteplase for patients with acute ischemic stroke. Objective To examine the safety and efficacy of tenecteplase compared to alteplase among patients with large vessel occlusion (LVO) stroke. Design, Setting, and Participants This was a prespecified analysis of the Intravenous Tenecteplase Compared With Alteplase for Acute Ischaemic Stroke in Canada (ACT) randomized clinical trial that enrolled patients from 22 primary and comprehensive stroke centers across Canada between December 10, 2019, and January 25, 2022. Patients 18 years and older with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly assigned (1:1) to either intravenous tenecteplase or alteplase and were monitored for up to 120 days. Patients with baseline intracranial internal carotid artery (ICA), M1-middle cerebral artery (MCA), M2-MCA, and basilar occlusions were included in this analysis. A total of 1600 patients were enrolled, and 23 withdrew consent. Exposures Intravenous tenecteplase (0.25 mg/kg) vs intravenous alteplase (0.9 mg/kg). Main Outcomes and Measures The primary outcome was the proportion of modified Rankin scale (mRS) score 0-1 at 90 days. Secondary outcomes were an mRS score from 0 to 2, mortality, and symptomatic intracerebral hemorrhage. Angiographic outcomes were successful reperfusion (extended Thrombolysis in Cerebral Infarction scale score 2b-3) on first and final angiographic acquisitions. Multivariable analyses (adjusting for age, sex, National Institute of Health Stroke Scale score, onset-to-needle time, and occlusion location) were carried out. Results Among 1577 patients, 520 (33.0%) had LVO (median [IQR] age, 74 [64-83] years; 283 [54.4%] women): 135 (26.0%) with ICA occlusion, 237 (45.6%) with M1-MCA, 117 (22.5%) with M2-MCA, and 31 (6.0%) with basilar occlusions. The primary outcome (mRS score 0-1) was achieved in 86 participants (32.7%) in the tenecteplase group vs 76 (29.6%) in the alteplase group. Rates of mRS 0-2 (129 [49.0%] vs 131 [51.0%]), symptomatic intracerebral hemorrhage (16 [6.1%] vs 11 [4.3%]), and mortality (19.9% vs 18.1%) were similar in the tenecteplase and alteplase groups, respectively. No difference was noted in successful reperfusion rates in the first (19 [9.2%] vs 21 [10.5%]) and final angiogram (174 [84.5%] vs 177 [88.9%]) among 405 patients who underwent thrombectomy. Conclusions and Relevance The findings in this study indicate that intravenous tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO.
Collapse
Affiliation(s)
- Fouzi Bala
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Internal Medicine, Neurology Division, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shelagh B. Coutts
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Yan Deschaintre
- Department of Neurosciences, Université de Montréal, Montréal, Québec, Canada
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | | | - Stephen Phillips
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre and McMaster University, Hamilton, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Ontario, Canada
| | - George Medvedev
- University of British Columbia and the Fraser Health Authority, New Westminster, British Columbia, Canada
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, London, Ontario, Canada
| | - Aleksandra Pikula
- Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Jai Jai Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Heather Williams
- Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada
| | - Thalia S. Field
- Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Atif Zafar
- St Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Faysal Benali
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - MacKenzie Horn
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D. Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Michel Shamy
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Ontario, Canada
| | - Tolulope T. Sajobi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Richard H. Swartz
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| |
Collapse
|
10
|
Alrohimi A, Rose DZ, Burgin WS, Renati S, Hilker N, Deng W, Oliveira G, Beckie T, Labovitz AJ, Fradley MG, Tran N, Gioia L, Kate M, Ng KH, Dowlatshahi D, Field TS, Coutts SB, Siddiqui M, Hill MD, Miller J, Jickling GC, Shuaib A, Buck B, Sharma M, Butcher K. Risk of Hemorrhagic Transformation with Early Use of Direct Oral Anticoagulants after Acute Ischemic Stroke: A Pooled Analysis of Prospective Studies and Randomized Trials. Int J Stroke 2023:17474930231164891. [PMID: 36907985 DOI: 10.1177/17474930231164891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Precise risk of hemorrhagic transformation (HT) in acute ischemic stroke (AIS) remains unknown, leading to delays in anticoagulation initiation for secondary stroke prevention. We sought to assess the rate of HT associated with direct oral anticoagulant (DOAC) initiation within and beyond 48 hours post-AIS. METHODS A pooled analysis of DOAC initiation within 14 days of AIS or transient ischemic attack (TIA) was conducted with 6 studies (4 prospective open label treatment, blinded outcome studies and 2 randomized trials; NCT02295826 and NCT02283294). The primary endpoint was incident radiographic HT on follow-up imaging (day 7-30). Secondary endpoints included symptomatic HT, new parenchymal hemorrhage, recurrent ischemic events, extracranial hemorrhage, study-period mortality, and follow-up modified Rankin Scale score. The results were reported as odds ratio (OR) or hazard ratio (HR) with 95% confidence interval (CI). RESULTS We evaluated 509 patients; median infarct volume was 1.5 (0.1-7.8) ml, and median National Institutes of Health Stroke Scale was 2 (0-3). Incident radiographic HT was seen on follow-up scan in 34 (6.8%) patients. DOAC initiation within 48 hours from index event was not associated with incident HT (adjusted OR 0.67, [0.30 - 1.50] P=0.32). No patients developed symptomatic HT. Conversely, 31 (6.1%) patients developed recurrent ischemic events, 64% of which occurred within 14 days. Initiating a DOAC within 48 hours of onset was associated with similar recurrent ischemic event rates compared to those in which treatment was delayed (HR 0.42, [0.17 - 1.008] P=0.052). In contrast to HT, recurrent ischemic events were associated with poor functional outcomes (OR=6.8, [2.84 - 16.24], p<0.001). CONCLUSIONS In this pooled analysis, initiation of DOAC within 48 hours post-stroke was not associated with increased incident risk of HT, and none developed symptomatic HT. The analysis was underpowered to determine the effect of early DOAC use upon recurrent ischemic events.
Collapse
Affiliation(s)
- Anas Alrohimi
- University of Alberta, Medicine, Edmonton, Canada 3158.,King Saud University, Medicine, Riyadh, Saudi Arabia.,Cleveland Clinic, Cerebrovascular Canter, Cleveland, OH, USA
| | - David Z Rose
- University of South Florida, Neurology, Tampa, FL, USA 33697
| | | | - Swetha Renati
- University of South Florida, Neurology, Tampa, FL, USA 7831
| | | | - Wei Deng
- University of South Florida, Medicine, Tampa, FL, USA 7831
| | | | - Theresa Beckie
- University of South Florida, College of Nursing, Tampa, FL, USA 7831
| | | | | | - Nhi Tran
- University of South Florida, Medicine, Tampa, FL, USA 7831
| | - Laura Gioia
- University of Montreal, Neurology, Montreal, Canada 25443
| | - Mahesh Kate
- University of Alberta, Medicine, Edmonton, Canada 3158
| | - Kuan H Ng
- McMaster University, Medicine, Hamilton, Canada 3710
| | | | | | - Shelagh B Coutts
- University of Calgary, Department of Clinical Neurosciences, Calgary, Canada 2129
| | | | - Michael D Hill
- University of Calgary, Department of Clinical Neurosciences, Calgary, Canada 2129
| | - Jodi Miller
- McMaster University, Medicine, Hamilton, Canada 3710
| | | | - Ashfaq Shuaib
- University of Alberta, Medicine, Edmonton, Canada 3158
| | - Brian Buck
- University of Alberta, Medicine, Edmonton, Canada 25484
| | - Mukul Sharma
- McMaster University, Medicine, Hamilton, Canada 3710
| | - Kenneth Butcher
- University of Alberta, Medicine, Edmonton, Canada 6804.,University of New South Wales, Sydney, Australia
| |
Collapse
|
11
|
Nair R, Sarmiento R, Sheriff A, Shuaib A, Buck B, Gauthier M, Mushahwar V, Ferguson-Pell M, Kate M. Assessment of remote ischemic conditioning delivery with optical sensor in acute ischemic stroke: Randomised clinical trial protocol. PLoS One 2023; 18:e0284879. [PMID: 37141237 PMCID: PMC10159200 DOI: 10.1371/journal.pone.0284879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Remote ischemic conditioning (RIC) is delivered by a blood pressure cuff over the limb, raising pressure 50 mmHg above the systolic blood pressure, to a maximum of 200 mmHg. The cuff is inflated for five minutes and then deflated for five minutes in a sequential ischemia-reperfusion cycle 4-5 times per session. Elevated pressure in the limb may be associated with discomfort and consequently reduced compliance. Continuous assessment of relative blood concentration and oxygenation with a tissue reflectance spectroscopy (a type of optical sensor device) placed over the forearm during the RIC sessions of the arm will allow us to observe the effect of inflation and deflation of the pressure cuff. We hypothesize, in patients with acute ischemic stroke (AIS) and small vessel disease, RIC delivered together with a tissue reflectance sensor will be feasible. METHODS The study is a prospective, single-center, randomized control trial testing the feasibility of the device. Patients with AIS within 7 days from symptoms onset; who also have small vessel disease will be randomized 2:1 to intervention or sham control arms. All patients randomized to the intervention arm will receive 5 cycles of ischemia/reperfusion in the non-paralyzed upper limb with a tissue reflectance sensor and patients in the sham control arm will receive pressure by keeping the cuff pressure at 30 mmHg for 5 minutes. A total of 51 patients will be randomized, 17 in the sham control arm and 34 in the intervention arm. The primary outcome measure will be the feasibility of RIC delivered for 7 days or at the time of discharge. The secondary device-related outcome measures are fidelity of RIC delivery and the completion rate of intervention. The secondary clinical outcome includes a modified Rankin scale, recurrent stroke and cognitive assessment at 90 days. DISCUSSION RIC delivery together with a tissue reflectance sensor will allow insight into the blood concentration and blood oxygenation changes in the skin. This will allow individualized delivery of the RIC and improve compliance. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05408130, June 7, 2022.
Collapse
Affiliation(s)
- Radhika Nair
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Sarmiento
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Asif Sheriff
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian Buck
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michel Gauthier
- Department of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vivian Mushahwar
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Martin Ferguson-Pell
- Department of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mahesh Kate
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
12
|
van de Munckhof A, Lindgren E, Kleinig TJ, Field TS, Cordonnier C, Krzywicka K, Poli S, Sánchez van Kammen M, Borhani-Haghighi A, Lemmens R, Scutelnic A, Ciccone A, Gattringer T, Wittstock M, Dizonno V, Devroye A, Elkady A, Günther A, Cervera A, Mengel A, Chew BLA, Buck B, Zanferrari C, Garcia-Esperon C, Jacobi C, Soriano C, Michalski D, Zamani Z, Blacquiere D, Johansson E, Cuadrado-Godia E, Vuillier F, Bode FJ, Caparros F, Maier F, Tsivgoulis G, Katzberg HD, Duan J, Burrow J, Pelz J, Mbroh J, Oen J, Schouten J, Zimmermann J, Ng K, Garambois K, Petruzzellis M, Carvalho Dias M, Ghiasian M, Romoli M, Miranda M, Wronski M, Skjelland M, Almasi-Dooghaee M, Cuisenier P, Murphy S, Timsit S, Coutts SB, Schönenberger S, Nagel S, Hiltunen S, Chatterton S, Cox T, Bartsch T, Shaygannejad V, Mirzaasgari Z, Middeldorp S, Levi MM, Kremer Hovinga JA, Jood K, Tatlisumak T, Putaala J, Heldner MR, Arnold M, Aguiar de Sousa D, Ferro JM, Coutinho JM. Outcomes of Cerebral Venous Thrombosis due to Vaccine-Induced Immune Thrombotic Thrombocytopenia After the Acute Phase. Stroke 2022; 53:3206-3210. [PMID: 36082668 PMCID: PMC9508952 DOI: 10.1161/strokeaha.122.039575] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral venous thrombosis (CVT) due to vaccine-induced immune thrombotic thrombocytopenia (VITT) is a severe condition, with high in-hospital mortality rates. Here, we report clinical outcomes of patients with CVT-VITT after SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) vaccination who survived initial hospitalization. METHODS We used data from an international registry of patients who developed CVT within 28 days of SARS-CoV-2 vaccination, collected until February 10, 2022. VITT diagnosis was classified based on the Pavord criteria. Outcomes were mortality, functional independence (modified Rankin Scale score 0-2), VITT relapse, new thrombosis, and bleeding events (all after discharge from initial hospitalization). RESULTS Of 107 CVT-VITT cases, 43 (40%) died during initial hospitalization. Of the remaining 64 patients, follow-up data were available for 60 (94%) patients (37 definite VITT, 9 probable VITT, and 14 possible VITT). Median age was 40 years and 45/60 (75%) patients were women. Median follow-up time was 150 days (interquartile range, 94-194). Two patients died during follow-up (3% [95% CI, 1%-11%). Functional independence was achieved by 53/60 (88% [95% CI, 78%-94%]) patients. No new venous or arterial thrombotic events were reported. One patient developed a major bleeding during follow-up (fatal intracerebral bleed). CONCLUSIONS In contrast to the high mortality of CVT-VITT in the acute phase, mortality among patients who survived the initial hospitalization was low, new thrombotic events did not occur, and bleeding events were rare. Approximately 9 out of 10 CVT-VITT patients who survived the acute phase were functionally independent at follow-up.
Collapse
Affiliation(s)
- Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (A.v.d.M., K.K., M.S.v.K., J.M.C.)
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.L., K.J., T.T.).,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (E.L., K.J., T.T.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia (T.J.K.)
| | - Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, Canada (T.S.F., V.D.)
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, France (C.C., F.C.)
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (A.v.d.M., K.K., M.S.v.K., J.M.C.)
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Germany. (S.P., A.M., J.M.).,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Germany. (S.P., J.M.)
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (A.v.d.M., K.K., M.S.v.K., J.M.C.)
| | | | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (R.L., A.D.)
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (A.S., M.R.H., M.A.)
| | - Alfonso Ciccone
- Department of Neurology, Carlo Poma Hospital, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy (A. Ciccone)
| | | | - Matthias Wittstock
- Department of Neurology, University Hospital Rostock, Germany (M. Wittstock)
| | - Vanessa Dizonno
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, Canada (T.S.F., V.D.)
| | - Annemie Devroye
- Department of Neurology, University Hospitals Leuven, Belgium (R.L., A.D.)
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia (A.E.)
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Germany (A.G.)
| | - Alvaro Cervera
- Royal Darwin Hospital, Darwin, Northern Territory, Australia (A. Cervera)
| | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Germany. (S.P., A.M., J.M.)
| | - Beng Lim Alvin Chew
- Department of Neurology, John Hunter Hospital, Newcastle, Australia (B.L.A.C., C.G.-E.)
| | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, Canada (B.B.)
| | - Carla Zanferrari
- Department of Neurology, Azienda Ospedaliera di Melegnano e della Martesana, Italy (C.Z.)
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, Australia (B.L.A.C., C.G.-E.)
| | - Christian Jacobi
- Department of Neurology, Krankenhaus Nordwest, Frankfurt am Main, Germany (C.J.)
| | - Cristina Soriano
- Department of Neurology, Hospital General de Castellón, Castelló, Spain (C.S.)
| | - Dominik Michalski
- Department of Neurology, Leipzig University Hospital, Germany (D.M., J. Pelz)
| | - Zohreh Zamani
- Department of Neurology, Firoozabadi Hospital, Firoozgar Hospital, School of Medicine, Iran University of Medical Sciences, Tehran. (Z.Z.)
| | | | - Elias Johansson
- Department Clinical Science, Wallenberg Center for Molecular Medicine (WCMM), Umeå University, Sweden (E.J.)
| | - Elisa Cuadrado-Godia
- Department of Neurology, University Hospital del Mar, Barcelona, Spain (E.C.-G.)
| | | | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Germany (F.J.B., J.Z.)
| | - François Caparros
- University Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, France (C.C., F.C.)
| | - Frank Maier
- Department of Neurology, Caritas Hospital Saarbrücken, Germany (F.M.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T.)
| | - Hans D Katzberg
- Department of Neuromuscular Medicine, Toronto General Hospital, Canada (H.D.K.)
| | - Jiangang Duan
- Department of Neurology and Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China (J.D.)
| | - Jim Burrow
- Department of Neurology, Royal Darwin Hospital, Tiwi, Australia (J.B.)
| | - Johann Pelz
- Department of Neurology, Leipzig University Hospital, Germany (D.M., J. Pelz)
| | - Joshua Mbroh
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Germany. (S.P., A.M., J.M.).,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Germany. (S.P., J.M.)
| | - Joyce Oen
- Department of Neurology, Antonius Ziekenhuis, Sneek, the Netherlands (J.O.)
| | - Judith Schouten
- Department of Neurology, Rijnstate Hospital Arnhem, the Netherlands (J.S.)
| | - Julian Zimmermann
- Department of Neurology, Universitätsklinikum Bonn, Germany (F.J.B., J.Z.)
| | - Karl Ng
- Department of Neurology, Royal North Shore Hospital, Sydney, Australia (K.N., M. Wronski, S.C.)
| | - Katia Garambois
- Department of Neurology, CHU Grenoble Alpes, France (K.G., P.C.)
| | - Marco Petruzzellis
- Department of Neurology, AOU Consorziale Policlinico di Bari, Italy (M.P.)
| | - Mariana Carvalho Dias
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, University of Lisbon, Portugal (M.C.D.)
| | - Masoud Ghiasian
- Department of Neurology, Sina Hospital, Hamadan University of Medical Science, Iran (M.G.)
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M.R.)
| | - Miguel Miranda
- Department of Neurology, Hospital de Cascais Dr. José de Almeida, Cascais, Portugal (M.M.)
| | - Miriam Wronski
- Department of Neurology, Royal North Shore Hospital, Sydney, Australia (K.N., M. Wronski, S.C.)
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Norway (M.S.)
| | | | | | - Seán Murphy
- Acute Stroke Service, Mater Misericordiae University Hospital, UCD School of Medicine and RCSI Medical School, Dublin, Ireland (S. Murphy)
| | - Serge Timsit
- Department of Neurology, Stroke Unit, Hôpital de la Cavale Blanche, CHRU de Brest (University Hospital), Université de Bretagne Occidentale, Inserm 1078, Brest, France (S.T.)
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Canada (S.B.C.)
| | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Germany (S.S., S.N.)
| | - Sini Hiltunen
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Finland (S.H., T.T., J. Putaala)
| | - Sophie Chatterton
- Department of Neurology, Royal North Shore Hospital, Sydney, Australia (K.N., M. Wronski, S.C.)
| | - Thomas Cox
- Department of Neurology, University Hospital Southampton NHS Foundation Trust, United Kingdom (T.C.)
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany (T.B.)
| | - Vahid Shaygannejad
- Isfahan University of Medical Sciences (IUMS), Isfahan Neurosciences Research Center (INRC), Iran (V.S.).,Department of Internal (INRC), Iran (V.S.)
| | - Zahra Mirzaasgari
- Department of Neurology, Firoozgar Hospital, School of Medicine, Iran University of Medical Sciences, Tehran. (M.A.-D., Z.M.)
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (S. Middeldorp)
| | - Marcel M Levi
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (M.M.L.).,National Institute for Health Research, University College London Hospitals (UCLH), Biomedical Research Centre, London, United Kingdom (M.M.L.)
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (J.A.K.H.)
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.L., K.J., T.T.).,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (E.L., K.J., T.T.)
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.L., K.J., T.T.).,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (E.L., K.J., T.T.).,Department of Neurology, Helsinki University Hospital, University of Helsinki, Finland (S.H., T.T., J. Putaala)
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Finland (S.H., T.T., J. Putaala)
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (A.S., M.R.H., M.A.)
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (A.S., M.R.H., M.A.)
| | - Diana Aguiar de Sousa
- Stroke Centre, Lisbon Central University Hospital Centre, Portugal (D.A.d.S.).,Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S., J.M.F.)
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S., J.M.F.)
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (A.v.d.M., K.K., M.S.v.K., J.M.C.)
| |
Collapse
|
13
|
Navarro C, Reese-Smith J, Lemacks J, Greer T, Aras S, Madson M, Gipson J, Buck B, Johnson M. A Snapshot of Modalities for Recruitment of African Americans for an Intensive Behavioral Therapy Weight Management Intervention during the COVID-19 Pandemic. J Acad Nutr Diet 2022. [PMCID: PMC9385438 DOI: 10.1016/j.jand.2022.06.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
14
|
Scutelnic A, Krzywicka K, Mbroh J, van de Munckhof A, van Kammen MS, de Sousa DA, Lindgren E, Jood K, Günther A, Hiltunen S, Putaala J, Tiede A, Maier F, Kern R, Bartsch T, Althaus K, Ciccone A, Wiedmann M, Skjelland M, Medina A, Cuadrado-Godia E, Cox T, Aujayeb A, Raposo N, Garambois K, Payen JF, Vuillier F, Franchineau G, Timsit S, Bougon D, Dubois MC, Tawa A, Tracol C, De Maistre E, Bonneville F, Vayne C, Mengel A, Michalski D, Pelz J, Wittstock M, Bode F, Zimmermann J, Schouten J, Buture A, Murphy S, Palma V, Negro A, Gutschalk A, Nagel S, Schoenenberger S, Frisullo G, Zanferrari C, Grillo F, Giammello F, Martin MM, Cervera A, Burrow J, Esperon CG, Chew BLA, Kleinig TJ, Soriano C, Zimatore DS, Petruzzellis M, Elkady A, Miranda MS, Fernandes J, Vogel ÅH, Johansson E, Philip AP, Coutts SB, Bal S, Buck B, Legault C, Blacquiere D, Katzberg HD, Field TS, Dizonno V, Gattringer T, Jacobi C, Devroye A, Lemmens R, Kristoffersen ES, di Poggio MB, Ghiasian M, Karapanayiotides T, Chatterton S, Wronski M, Ng K, Kahnis R, Geeraerts T, Reiner P, Cordonnier C, Middeldorp S, Levi M, van Gorp ECM, van de Beek D, Brodard J, Kremer Hovinga JA, Kruip MJHA, Tatlisumak T, Ferro JM, Coutinho JM, Arnold M, Poli S, Heldner MR. Management of Cerebral Venous Thrombosis Due to Adenoviral COVID-19 Vaccination. Ann Neurol 2022; 92:562-573. [PMID: 35689346 PMCID: PMC9349982 DOI: 10.1002/ana.26431] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/21/2022] [Accepted: 05/27/2022] [Indexed: 01/01/2023]
Abstract
Objective Cerebral venous thrombosis (CVT) caused by vaccine‐induced immune thrombotic thrombocytopenia (VITT) is a rare adverse effect of adenovirus‐based severe acute respiratory syndrome‐coronavirus 2 (SARS‐CoV‐2) vaccines. In March 2021, after autoimmune pathogenesis of VITT was discovered, treatment recommendations were developed. These comprised immunomodulation, non‐heparin anticoagulants, and avoidance of platelet transfusion. The aim of this study was to evaluate adherence to these recommendations and its association with mortality. Methods We used data from an international prospective registry of patients with CVT after the adenovirus‐based SARS‐CoV‐2 vaccination. We analyzed possible, probable, or definite VITT‐CVT cases included until January 18, 2022. Immunomodulation entailed administration of intravenous immunoglobulins and/or plasmapheresis. Results Ninety‐nine patients with VITT‐CVT from 71 hospitals in 17 countries were analyzed. Five of 38 (13%), 11 of 24 (46%), and 28 of 37 (76%) of the patients diagnosed in March, April, and from May onward, respectively, were treated in‐line with VITT recommendations (p < 0.001). Overall, treatment according to recommendations had no statistically significant influence on mortality (14/44 [32%] vs 29/55 [52%], adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.16–1.19). However, patients who received immunomodulation had lower mortality (19/65 [29%] vs 24/34 [70%], adjusted OR = 0.19, 95% CI = 0.06–0.58). Treatment with non‐heparin anticoagulants instead of heparins was not associated with lower mortality (17/51 [33%] vs 13/35 [37%], adjusted OR = 0.70, 95% CI = 0.24–2.04). Mortality was also not significantly influenced by platelet transfusion (17/27 [63%] vs 26/72 [36%], adjusted OR = 2.19, 95% CI = 0.74–6.54). Conclusions In patients with VITT‐CVT, adherence to VITT treatment recommendations improved over time. Immunomodulation seems crucial for reducing mortality of VITT‐CVT. ANN NEUROL 2022;92:562–573
Collapse
Affiliation(s)
- Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Joshua Mbroh
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany.,Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sini Hiltunen
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andreas Tiede
- Clinic for Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Frank Maier
- Department of Neurology, Caritas Hospital Saarbrücken, Saarbrücken, Germany
| | - Rolf Kern
- Department of Neurology, Kempten Hospital, Kempten, Germany
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Alfonso Ciccone
- Department of Neurology, Carlo Poma Hospital, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Markus Wiedmann
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Mona Skjelland
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Antonio Medina
- Department of Neurology, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Thomas Cox
- Department of Neurology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Nicolas Raposo
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Katia Garambois
- Stroke Unit, University Hospital of Grenoble, Grenoble, France
| | | | | | - Guillaume Franchineau
- Department of Intensive Care, Centre Hospitalier Intercommunal de Poissy Saint Germain en Laye, Poissy, France
| | - Serge Timsit
- Neurology and Stroke Unit, Centre Hospitalier Universitaire de Brest, CHU Brest, Brest, France
| | - David Bougon
- Department of Critical Care, Annecy Genevois Hospital, Annecy, France
| | - Marie-Cécile Dubois
- Department of Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | - Audrey Tawa
- Department of Anesthesia and Intensive Care, University Hospital of Rennes, Rennes, France
| | | | | | - Fabrice Bonneville
- Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Caroline Vayne
- Department of Hematology and Hemostasis, Tours University Hospital, Tours, France
| | - Annerose Mengel
- Department of Neurology and Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Dominik Michalski
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | | | - Felix Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Judith Schouten
- Department of Neurology, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
| | - Alina Buture
- Acute Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Murphy
- Acute Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Vincenzo Palma
- Department of Neuroradiology, Ospedale del Mare, Naples, Italy
| | - Alberto Negro
- Department of Neuroradiology, Ospedale del Mare, Naples, Italy
| | - Alexander Gutschalk
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Giovanni Frisullo
- Department of Neurology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carla Zanferrari
- Department of Neurology, Azienda Ospedaliera di Melegnano e della Martesana, Melegnano, Italy
| | - Francesco Grillo
- Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery, XXXV Cycle, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Mar Morin Martin
- Department of Neurology, Hospital Complex of Toledo, Toledo, Spain
| | - Alvaro Cervera
- Department of Neurology, Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Jim Burrow
- Department of Neurology, Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Carlos Garcia Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Beng Lim Alvin Chew
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Cristina Soriano
- Department of Neurology, Hospital General de Castellón, Castelló, Spain
| | | | - Marco Petruzzellis
- Department of Neurology, AOU Consorziale Policlinico di Bari, Bari, Italy
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia
| | - Miguel S Miranda
- Department of Neurology, Hospital de Cascais Dr José de Almeida, Cascais, Portugal
| | - João Fernandes
- Department of Neurology, Norra Älvsborgs Länssjukhus, Trollhattan, Sweden
| | | | - Elias Johansson
- Clinical Science, Neurosciences, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå, Sweden
| | | | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Simerpreet Bal
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Catherine Legault
- Department of Neurology and Neurosurgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dylan Blacquiere
- Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hans D Katzberg
- Department of Neuromuscular Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | - Vanessa Dizonno
- Division of Neurology, University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | | | - Christian Jacobi
- Department of Neurology, Nordwest Hospital, Frankfurt am Main, Germany
| | - Annemie Devroye
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Masoud Ghiasian
- Department of Neurology, Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | | | - Sophie Chatterton
- Department of Neurology, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Miriam Wronski
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Karl Ng
- Department of Neurology and Clinical Neurophysiology, Royal North Shore Hospital and The University of Sydney, Sydney, New South Wales, Australia
| | - Robert Kahnis
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Thomas Geeraerts
- Department of Anaesthesiology and Critical Care, University Toulouse 3-Paul-Sabatier, University Hospital of Toulouse, Hôpital Pierre-Paul Riquet, CHU Toulouse-Purpan, Toulouse, France
| | - Peggy Reiner
- Service de neurologie, hôpital Lariboisière Université Paris-7, AP-HP, Paris Cedex 10, France
| | - Charlotte Cordonnier
- University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel Levi
- National Institute for Health Research University College London Hospitals (UCLH) Biomedical Research Centre, London, UK.,Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric C M van Gorp
- Department of Viroscience, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Justine Brodard
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Turgut Tatlisumak
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Poli
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany.,Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
15
|
Faris H, Dewar B, Dowlatshahi D, Ramji A, Kenney C, Page S, Buck B, Hill MD, Coutts SB, Almekhlafi M, Sajobi T, Singh N, Sehgal A, Swartz RH, Menon BK, Shamy M. Ethical Justification for Deferral of Consent in the AcT Trial for Acute Ischemic Stroke. Stroke 2022; 53:2420-2423. [DOI: 10.1161/strokeaha.122.038760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The AcT trial (Alteplase Compared to Tenecteplase) compares alteplase or tenecteplase for patients with acute ischemic stroke. All eligible patients are enrolled by deferral of consent. Although the use of deferral of consent in the AcT trial meets the requirements of Canadian policy, we sought to provide a more explicit and rigorous approach to the justification of deferral of consent organized around 3 questions. Ultimately, the approach we outline here could become the foundation for a general justification for deferral of consent.
Collapse
Affiliation(s)
- Hannah Faris
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ontario, Canada (H.F., D.D., M.S.)
- Ottawa Hospital Research Institute, Ontario, Canada (H.F., B.D., D.D., M.S.)
| | - Brian Dewar
- Ottawa Hospital Research Institute, Ontario, Canada (H.F., B.D., D.D., M.S.)
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ontario, Canada (H.F., D.D., M.S.)
- Ottawa Hospital Research Institute, Ontario, Canada (H.F., B.D., D.D., M.S.)
| | | | - Carol Kenney
- Calgary Stroke Program, University of Calgary and Foothills Hospital, Alberta, Canada (C.K., M.D.H., S.B.C., M.A., T.S., N.S., A.S., B.K.M.)
| | - Stacey Page
- Calgary Conjoint Health Research Ethics Board, Alberta, Canada (S.P.)
| | - Brian Buck
- University of Alberta and University Hospital, Edmonton, Canada (B.B.)
| | - Michael D. Hill
- Calgary Stroke Program, University of Calgary and Foothills Hospital, Alberta, Canada (C.K., M.D.H., S.B.C., M.A., T.S., N.S., A.S., B.K.M.)
| | - Shelagh B. Coutts
- Calgary Stroke Program, University of Calgary and Foothills Hospital, Alberta, Canada (C.K., M.D.H., S.B.C., M.A., T.S., N.S., A.S., B.K.M.)
| | - Mohammed Almekhlafi
- Calgary Stroke Program, University of Calgary and Foothills Hospital, Alberta, Canada (C.K., M.D.H., S.B.C., M.A., T.S., N.S., A.S., B.K.M.)
| | - Tolulope Sajobi
- Calgary Stroke Program, University of Calgary and Foothills Hospital, Alberta, Canada (C.K., M.D.H., S.B.C., M.A., T.S., N.S., A.S., B.K.M.)
| | - Nishita Singh
- Calgary Stroke Program, University of Calgary and Foothills Hospital, Alberta, Canada (C.K., M.D.H., S.B.C., M.A., T.S., N.S., A.S., B.K.M.)
| | - Arshia Sehgal
- Calgary Stroke Program, University of Calgary and Foothills Hospital, Alberta, Canada (C.K., M.D.H., S.B.C., M.A., T.S., N.S., A.S., B.K.M.)
| | - Richard H. Swartz
- University of Toronto and Sunnybrook Hospital, Ontario, Canada (R.H.S.)
| | - Bijoy K. Menon
- Calgary Stroke Program, University of Calgary and Foothills Hospital, Alberta, Canada (C.K., M.D.H., S.B.C., M.A., T.S., N.S., A.S., B.K.M.)
| | - Michel Shamy
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ontario, Canada (H.F., D.D., M.S.)
- Ottawa Hospital Research Institute, Ontario, Canada (H.F., B.D., D.D., M.S.)
| |
Collapse
|
16
|
Sánchez van Kammen M, Aguiar de Sousa D, Poli S, Cordonnier C, Heldner MR, van de Munckhof A, Krzywicka K, van Haaps T, Ciccone A, Middeldorp S, Levi MM, Kremer Hovinga JA, Silvis S, Hiltunen S, Mansour M, Arauz A, Barboza MA, Field TS, Tsivgoulis G, Nagel S, Lindgren E, Tatlisumak T, Jood K, Putaala J, Ferro JM, Arnold M, Coutinho JM, Sharma AR, Elkady A, Negro A, Günther A, Gutschalk A, Schönenberger S, Buture A, Murphy S, Paiva Nunes A, Tiede A, Puthuppallil Philip A, Mengel A, Medina A, Hellström Vogel Å, Tawa A, Aujayeb A, Casolla B, Buck B, Zanferrari C, Garcia-Esperon C, Vayne C, Legault C, Pfrepper C, Tracol C, Soriano C, Guisado-Alonso D, Bougon D, Zimatore DS, Michalski D, Blacquiere D, Johansson E, Cuadrado-Godia E, De Maistre E, Carrera E, Vuillier F, Bonneville F, Giammello F, Bode FJ, Zimmerman J, d'Onofrio F, Grillo F, Cotton F, Caparros F, Puy L, Maier F, Gulli G, Frisullo G, Polkinghorne G, Franchineau G, Cangür H, Katzberg H, Sibon I, Baharoglu I, Brar J, Payen JF, Burrow J, Fernandes J, Schouten J, Althaus K, Garambois K, Derex L, Humbertjean L, Lebrato Hernandez L, Kellermair L, Morin Martin M, Petruzzellis M, Cotelli M, Dubois MC, Carvalho M, Wittstock M, Miranda M, Skjelland M, Bandettini di Poggio M, Scholz MJ, Raposo N, Kahnis R, Kruyt N, Huet O, Sharma P, Candelaresi P, Reiner P, Vieira R, Acampora R, Kern R, Leker R, Coutts S, Bal S, Sharma SS, Susen S, Cox T, Geeraerts T, Gattringer T, Bartsch T, Kleinig TJ, Dizonno V, Arslan Y. Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia. JAMA Neurol 2021; 78:1314-1323. [PMID: 34581763 DOI: 10.1001/jamaneurol.2021.3619] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Thrombosis with thrombocytopenia syndrome (TTS) has been reported after vaccination with the SARS-CoV-2 vaccines ChAdOx1 nCov-19 (Oxford-AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson). Objective To describe the clinical characteristics and outcome of patients with cerebral venous sinus thrombosis (CVST) after SARS-CoV-2 vaccination with and without TTS. Design, Setting, and Participants This cohort study used data from an international registry of consecutive patients with CVST within 28 days of SARS-CoV-2 vaccination included between March 29 and June 18, 2021, from 81 hospitals in 19 countries. For reference, data from patients with CVST between 2015 and 2018 were derived from an existing international registry. Clinical characteristics and mortality rate were described for adults with (1) CVST in the setting of SARS-CoV-2 vaccine-induced immune thrombotic thrombocytopenia, (2) CVST after SARS-CoV-2 vaccination not fulling criteria for TTS, and (3) CVST unrelated to SARS-CoV-2 vaccination. Exposures Patients were classified as having TTS if they had new-onset thrombocytopenia without recent exposure to heparin, in accordance with the Brighton Collaboration interim criteria. Main Outcomes and Measures Clinical characteristics and mortality rate. Results Of 116 patients with postvaccination CVST, 78 (67.2%) had TTS, of whom 76 had been vaccinated with ChAdOx1 nCov-19; 38 (32.8%) had no indication of TTS. The control group included 207 patients with CVST before the COVID-19 pandemic. A total of 63 of 78 (81%), 30 of 38 (79%), and 145 of 207 (70.0%) patients, respectively, were female, and the mean (SD) age was 45 (14), 55 (20), and 42 (16) years, respectively. Concomitant thromboembolism occurred in 25 of 70 patients (36%) in the TTS group, 2 of 35 (6%) in the no TTS group, and 10 of 206 (4.9%) in the control group, and in-hospital mortality rates were 47% (36 of 76; 95% CI, 37-58), 5% (2 of 37; 95% CI, 1-18), and 3.9% (8 of 207; 95% CI, 2.0-7.4), respectively. The mortality rate was 61% (14 of 23) among patients in the TTS group diagnosed before the condition garnered attention in the scientific community and 42% (22 of 53) among patients diagnosed later. Conclusions and Relevance In this cohort study of patients with CVST, a distinct clinical profile and high mortality rate was observed in patients meeting criteria for TTS after SARS-CoV-2 vaccination.
Collapse
Affiliation(s)
- Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, University of Lisbon, Lisbon, Portugal
| | - Sven Poli
- Department of Neurology and Stroke, Eberhard-Karls University, Tuebingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Charlotte Cordonnier
- Department of Neurosciences and Cognition, Lille University Hospital, Lille, France
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Thijs van Haaps
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Alfonso Ciccone
- Department of Neurology, Carlo Poma Hospital, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel M Levi
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Suzanne Silvis
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Sini Hiltunen
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Maryam Mansour
- Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | - Antonio Arauz
- National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Mexico City, Mexico
| | - Miguel A Barboza
- Neurosciences Department, Hospital Dr R.A. Calderón Guardia, San José, Costa Rica
| | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | - Georgios Tsivgoulis
- Second Department of Neurology in National, Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jose M Ferro
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, University of Lisbon, Lisbon, Portugal
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Aarti R Sharma
- Imperial College London School of Medicine, Imperial College London, London, United Kingdom
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia
| | - Alberto Negro
- Department of Neuroradiology, Ospedale del Mare, Naples, Italy
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Alexander Gutschalk
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Alina Buture
- Acute Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Murphy
- Acute Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,School of Medicine, University of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ana Paiva Nunes
- Department of Neurology, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Andreas Tiede
- Clinic for Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tuebingen, Tuebingen, Germany
| | - Antonio Medina
- Department of Neurology, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Audrey Tawa
- Department of Anesthesia and Intensive Care, University Hospital of Rennes, Rennes, France
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, Cramlington, United Kingdom
| | - Barbara Casolla
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, Cramlington, United Kingdom.,Stroke Unit, Hôpital Pasteur 2, URRIS - UR2CA, Unité de Recherche Clinique Cote d'Azur, Cote d'Azur University, Nice, France
| | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Carla Zanferrari
- Department of Neurology, Azienda Ospedaliera di Melegnano e della Martesana, Melegnano, Italy
| | | | - Caroline Vayne
- Department of Hematology and Hemostasis, Tours University Hospital, Tours, France
| | - Catherine Legault
- Department of Neurology and Neurosurgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christian Pfrepper
- Division of Hemostaseology, Leipzig University Hospital, Leipzig, Germany
| | | | - Cristina Soriano
- Department of Neurology, Hospital General de Castellón, Castelló, Spain
| | | | - David Bougon
- Department of Critical Care, Annecy Genevois Hospital, Annecy, France
| | | | - Dominik Michalski
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Dylan Blacquiere
- Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elias Johansson
- Department Clinical Science, Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden
| | | | | | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Fabrice Bonneville
- Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery, XXXV Cycle, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | - Julian Zimmerman
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Francesco Grillo
- Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Francois Cotton
- Department of Radiology, Lyon University Hospital, Lyon, France
| | - François Caparros
- Department of Neurosciences and Cognition, Lille University Hospital, Lille, France
| | - Laurent Puy
- Department of Neurosciences and Cognition, Lille University Hospital, Lille, France
| | - Frank Maier
- Department of Neurology, Caritas Hospital Saarbrücken, Saarbrücken, Germany
| | - Giosue Gulli
- Department of Medicine, Ashford and St Peters Hospital NHS Foundation Trust, Surrey, United Kingdom
| | - Giovanni Frisullo
- Department of Neurology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Guillaume Franchineau
- Department of Intensive Care, Centre Hospitalier Intercommunal de Poissy Saint Germain en Laye, Poissy, France
| | - Hakan Cangür
- Department of Neurology, Hospital of the City of Wolfsburg, Wolfsburg, Germany
| | - Hans Katzberg
- Department of Neuromuscular Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Igor Sibon
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Irem Baharoglu
- Department of Neurology, Haga Hospital, The Hague, the Netherlands
| | - Jaskiran Brar
- Department of Neurology, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | | | - Jim Burrow
- Department of Neurology, Royal Darwin Hospital, Tiwi, Australia
| | - João Fernandes
- Department of Neurology, Norra Älvsborgs Länssjukhus, Trollhattan, Sweden
| | - Judith Schouten
- Department of Neurology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | | | - Katia Garambois
- Stroke Unit, University Hospital of Grenoble, Grenoble, France
| | - Laurent Derex
- Department of Neurology, Hospices Civils de Lyon, Lyon, France
| | | | | | - Lukas Kellermair
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Mar Morin Martin
- Department of Neurology, Hospital Complex of Toledo, Toledo, Spain
| | - Marco Petruzzellis
- Department of Neurology, AOU Consorziale Policlinico di Bari, Bari, Italy
| | - Maria Cotelli
- Department of Neurology, ASL Vallecamonica-Sebino, Breno, Italy
| | - Marie-Cécile Dubois
- Department of Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | - Marta Carvalho
- Department of Neurology, Centro Hospitalar Universitário de São João, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Miguel Miranda
- Department of Neurology, Hospital de Cascais Dr José de Almeida, Cascais, Portugal
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Moritz J Scholz
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Nicolas Raposo
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Robert Kahnis
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Nyika Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Olivier Huet
- UFR de Bio-médecine, Hospital de la Cavale Blanche, CHRU de Brest, Brest, France
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London, London, United Kingdom
| | - Paolo Candelaresi
- Department of Neurology and Stroke, Cardarelli Hospital, Naples, Italy
| | - Peggy Reiner
- Department of Neurology, Lariboisière Hospital, Paris, France
| | - Ricardo Vieira
- Department of Hematology, Universidade Federal do Cariri, Juazeiro do Norte, Brazil
| | | | - Rolf Kern
- Department of Neurology, Kempten Hospital, Kempten, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah University Medical Center, Jerusalem, Israel
| | - Shelagh Coutts
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Simerpreet Bal
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Shyam S Sharma
- Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - Sophie Susen
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
| | - Thomas Cox
- Department of Neurology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France
| | | | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Vanessa Dizonno
- Division of Neurology, University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | - Yildiz Arslan
- Neurology Clinic, Medicana İzmir International Hospital, Izmir, Turkey
| |
Collapse
|
17
|
Soltanpour M, Greiner R, Boulanger P, Buck B. Improvement of automatic ischemic stroke lesion segmentation in CT perfusion maps using a learned deep neural network. Comput Biol Med 2021; 137:104849. [PMID: 34530336 DOI: 10.1016/j.compbiomed.2021.104849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/11/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
Acute ischemic stroke is one of the leading causes of death and long-term disability worldwide. It occurs when a blood clot blocks an artery that supplies blood to the brain tissue. Segmentation of acute ischemic stroke lesions plays a vital role to improve diagnosis, outcome assessment, and treatment planning. The current standard approach of ischemic stroke lesion segmentation is simply thresholding the Computed Tomography Perfusion (CTP) maps, i.e., quantitative feature maps created by summarizing CTP time sequence scans. However, this approach is not precise enough (its Dice similarity score is only around 50%) to be used in practice. Numerous machine learning-based techniques have recently been proposed to improve the accuracy of ischemic stroke lesion segmentation. Although they have achieved remarkable results, they still need to be improved before they can be used in actual practice. This paper presents a novel deep learning-based technique, MutiRes U-Net, for the segmentation of ischemic stroke lesions in CTP maps. MultiRes U-Net is a modified version of the original U-Net that is re-designed to be robust to segment the objects in different scales and unusual appearances. Additionally, in this paper, we propose to enrich the input CTP maps by using their contra-lateral and corresponding Tmax images. We evaluated the proposed method using the ISLES challenge 2018 dataset. As compared to the state-of-the-art methods, the results show an improvement in segmentation task accuracy. The dice similarity score (DSC) was 68%, the Jaccard score was 57.13%, and the mean absolute volume error was 22.62(ml).
Collapse
Affiliation(s)
| | - Russ Greiner
- Department of Computing Science, University of Alberta, Canada.
| | | | - Brian Buck
- Department of Medicine, University of Alberta, Canada.
| |
Collapse
|
18
|
Ospel JM, Brown S, Kappelhof M, van Zwam W, Jovin T, Roy D, Campbell BCV, Mitchell P, Roos Y, Guillemin F, Buck B, Muir K, Bracard S, White P, du Mesnil de Rochemont R, Goyal M. Comparing the Prognostic Impact of Age and Baseline National Institutes of Health Stroke Scale in Acute Stroke due to Large Vessel Occlusion. Stroke 2021; 52:2839-2845. [PMID: 34233465 DOI: 10.1161/strokeaha.120.032364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Johanna Maria Ospel
- Department of Clinical Neurosciences (J.M.O., M.G.), University of Calgary, Alberta, Canada.,Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.)
| | - Scott Brown
- Altair Biostatistics, St Louis Park, MN (S.B.)
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands (M.K.)
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, School for Mental Health and Sciences, Maastricht University Medical Center, the Netherlands (W.v.Z.)
| | - Tudor Jovin
- Department of Neurology, University of Pittsburgh, PA (T.J.)
| | - Daniel Roy
- Centre Hospitalier de l'Université de Montréal, Canada (D.R.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (B.C.V.C.)
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia (P.M.)
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands (Y.R.)
| | - Francis Guillemin
- Department of Clinical Epidemiology, Université de Lorraine, University Hospital of Nancy, France (F.G.)
| | - Brian Buck
- University of Alberta Hospital, Edmonton, Canada (B.B.)
| | - Keith Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Scotland (K.M.)
| | - Serge Bracard
- Department of Radiology, Université de Lorraine, Nancy, France (S.B.)
| | - Phil White
- Department of Radiology, Newcastle University, Newcastle Upon Tyne, United Kingdom (P.W.)
| | | | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., M.G.), University of Calgary, Alberta, Canada.,Department of Radiology (M.G.), University of Calgary, Alberta, Canada
| | | |
Collapse
|
19
|
Lysaker PH, Cheli S, Dimaggio G, Buck B, Bonfils KA, Huling K, Wiesepape C, Lysaker JT. Metacognition, social cognition, and mentalizing in psychosis: are these distinct constructs when it comes to subjective experience or are we just splitting hairs? BMC Psychiatry 2021; 21:329. [PMID: 34215225 PMCID: PMC8254212 DOI: 10.1186/s12888-021-03338-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/21/2021] [Indexed: 02/01/2023] Open
Abstract
Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised - as often occurs in psychosis - results in the loss of persons' sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.
Collapse
Affiliation(s)
- P H Lysaker
- Richard L Roudebush VA Medical Center, Department of Psychiatry, 1481 W. 10th St., Indianapolis, IN, 46202, USA. .,Department of Psychiatry, Indiana University School of Medicine, 340 W. 10th St., Indianapolis, IN, 46202, USA.
| | - S Cheli
- University of Florence, School of Human Health Sciences, Piazza di San Marco, 4, 50121, Florence, FI, Italy
| | - G Dimaggio
- Terzocentro di Psicoterapia Cognitiva, Associazione di Psicologia Cognitiva, Via Ravenna, 9, 00161, Rome, RM, Italy
| | - B Buck
- Department of Psychiatry and Behavioral Sciences, University of Washington, Behavioral Research in Technology and Engineering (BRiTE) Center, 1851 NE Grant Ln., Seattle, WA, 98185, USA
| | - K A Bonfils
- University of Southern Mississippi, School of Psychology, 118 College Dr., Hattiesbury, MS, 39406, USA
| | - K Huling
- University of Indianapolis, School of Psychological Sciences, 1400 E. Hanna Ave., Indianapolis, IN, 46277, USA
| | - C Wiesepape
- Indiana State University, Department of Psychology, 200 N. 7th St., Terre Haute, IN, 47809, USA
| | - J T Lysaker
- Department of Philosophy, Emory University, 201 Dowman Dr., Atlanta, GA, 30322, USA
| |
Collapse
|
20
|
Ospel JM, Hill MD, Menon BK, Demchuk A, McTaggart R, Nogueira R, Poppe A, Haussen D, Qiu W, Mayank A, Almekhlafi M, Zerna C, Joshi M, Jayaraman M, Roy D, Rempel J, Buck B, Tymianski M, Goyal M. Strength of Association between Infarct Volume and Clinical Outcome Depends on the Magnitude of Infarct Size: Results from the ESCAPE-NA1 Trial. AJNR Am J Neuroradiol 2021; 42:1375-1379. [PMID: 34167959 DOI: 10.3174/ajnr.a7183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/17/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Infarct volume is an important predictor of clinical outcome in acute stroke. We hypothesized that the association of infarct volume and clinical outcome changes with the magnitude of infarct size. MATERIALS AND METHODS Data were derived from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, in which patients with acute stroke with large-vessel occlusion were randomized to endovascular treatment plus either nerinetide or a placebo. Infarct volume was manually segmented on 24-hour noncontrast CT or DWI. The relationship between infarct volume and good outcome, defined as mRS 0-2 at 90 days, was plotted. Patients were categorized on the basis of visual grouping at the curve shoulders of the infarct volume/outcome plot. The relationship between infarct volume and adjusted probability of good outcome was fitted with linear or polynomial functions as appropriate in each group. RESULTS We included 1099 individuals in the study. Median infarct volume at 24 hours was 24.9 mL (interquartile range [IQR] = 6.6-92.2 mL). On the basis of the infarct volume/outcome plot, 4 infarct volume groups were defined (IQR = 0-15 mL, 15.1-70 mL, 70.1-200 mL, >200 mL). Proportions of good outcome in the 4 groups were 359/431 (83.3%), 219/337 (65.0%), 71/201 (35.3%), and 16/130 (12.3%), respectively. In small infarcts (IQR = 0-15 mL), no relationship with outcome was appreciated. In patients with intermediate infarct volume (IQR = 15-200 mL), there was progressive importance of volume as an outcome predictor. In infarcts of > 200 mL, outcomes were overall poor. CONCLUSIONS The relationship between infarct volume and clinical outcome varies nonlinearly with the magnitude of infarct size. Infarct volume was linearly associated with decreased chances of achieving good outcome in patients with moderate-to-large infarcts, but not in those with small infarcts. In very large infarcts, a near-deterministic association with poor outcome was seen.
Collapse
Affiliation(s)
- J M Ospel
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (J.M.O.), University Hospital of Basel, Basel, Switzerland
| | - M D Hill
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A Demchuk
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - R McTaggart
- Department of Interventional Radiology (R.M., M. Jayaraman), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - R Nogueira
- Department of Neurology (R.N., D.H.), Emory University School of Medicine, Atlanta, Georgia
| | - A Poppe
- Centre Hospitalier de l'Université de Montréal (A.P., D.R.), Montreal, Quebec, Canada
| | - D Haussen
- Department of Neurology (R.N., D.H.), Emory University School of Medicine, Atlanta, Georgia
| | - W Qiu
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A Mayank
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - C Zerna
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M Joshi
- Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M Jayaraman
- Department of Interventional Radiology (R.M., M. Jayaraman), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - D Roy
- Centre Hospitalier de l'Université de Montréal (A.P., D.R.), Montreal, Quebec, Canada
| | - J Rempel
- University of Alberta Hospital (J.R., B.B.), Edmonton, Alberta, Canada
| | - B Buck
- University of Alberta Hospital (J.R., B.B.), Edmonton, Alberta, Canada
| | | | - M Goyal
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada .,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
21
|
Ospel JM, Qiu W, Menon BK, Mayank A, Demchuk A, McTaggart R, Nogueira RG, Poppe AY, Jayaraman M, Buck B, Haussen D, Roy D, Joshi M, Zerna C, Almekhlafi M, Tymianski M, Hill MD, Goyal M. Radiologic Patterns of Intracranial Hemorrhage and Clinical Outcome after Endovascular Treatment in Acute Ischemic Stroke: Results from the ESCAPE-NA1 Trial. Radiology 2021; 300:402-409. [PMID: 34060942 DOI: 10.1148/radiol.2021204560] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Intracranial hemorrhage is a known complication after endovascular treatment in patients with acute ischemic stroke due to large vessel occlusion, but the association between radiologic hemorrhage severity and outcome is controversial. Purpose To investigate the prevalence and impact on outcome of intracranial hemorrhage and hemorrhage severity after endovascular stroke treatment. Materials and Methods The Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke (ESCAPE-NA1) trial enrolled participants with acute large vessel occlusion stroke who underwent endovascular treatment from March 1, 2017, to August 12, 2019. Evidence of any intracranial hemorrhage, hemorrhage multiplicity, and radiologic severity, according to the Heidelberg classification (hemorrhagic infarction type 1 [HI1], hemorrhagic infarction type 2 [HI2], parenchymal hematoma type 1 [PH1], and parenchymal hematoma type 2 [PH2]) was assessed at CT or MRI 24 hours after endovascular treatment. Good functional outcome, defined as a modified Rankin score of 0-2 at 90 days, was compared between participants with intracranial hemorrhage and those without intracranial hemorrhage at follow-up imaging and between hemorrhage subtypes. Poisson regression was performed to obtain adjusted effect size estimates for the presence of any intracranial hemorrhage and hemorrhage subtypes at good functional outcome. Results Of 1097 evaluated participants (mean age, 69 years ± 14 [standard deviation]; 551 men), any degree of intracranial hemorrhage was observed in 372 (34%). Good outcomes were less often achieved among participants with hemorrhage than among those without hemorrhage at follow-up imaging (164 of 372 participants [44%] vs 500 of 720 [69%], respectively; P < .01). After adjusting for baseline variables and infarct volume, intracranial hemorrhage was not associated with decreased chances of good outcome (adjusted risk ratio [RR] = 0.91 [95% CI: 0.82, 1.02], P = .10), but there was a graded relationship of radiologic hemorrhage severity and outcomes, whereby PH1 (RR = 0.77 [95% CI: 0.61, 0.97], P = .03) and PH2 (RR = 0.41 [95% CI: 0.21, 0.81], P = .01) were associated with decreased chances of good outcome. Conclusion Any degree of intracranial hemorrhage after endovascular treatment was seen in one-third of participants. A graded association existed between radiologic hemorrhage severity and outcome. Hemorrhagic infarction was not associated with outcome, whereas parenchymal hematoma was strongly associated with poor outcome, independent of infarct volume. © RSNA, 2021 Clinical trial registration no. NCT01778335 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Johanna M Ospel
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Wu Qiu
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Bijoy K Menon
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Arnuv Mayank
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Andrew Demchuk
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Ryan McTaggart
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Raul G Nogueira
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Alexandre Y Poppe
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Mahesh Jayaraman
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Brian Buck
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Diogo Haussen
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Daniel Roy
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Manish Joshi
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Charlotte Zerna
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Mohammed Almekhlafi
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Michael Tymianski
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Michael D Hill
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | - Mayank Goyal
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| | -
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., W.Q., B.K.M., A.M., A.D., C.Z., M.A., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Canada (B.K.M., A.D., M. Joshi, M.A., M.D.H., M.G.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.M., M. Jayaraman); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Neurology (D.R.) and Neurosciences (A.Y.P.), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Medicine, University of Alberta Hospital, Edmonton, Canada (B.B.); and NoNo, Toronto, Canada (M.T.)
| |
Collapse
|
22
|
Alrohimi A, Jickling G, Jeerakathil T, Shuaib A, Khan K, Kate M, Hill MD, Buck B, Butcher K. Protocol for LASER: A Randomized Evaluation and an Associated Registry of Early Anticoagulation With Edoxaban After Ischemic Stroke in Patients With Atrial Fibrillation. Front Neurol 2021; 12:645822. [PMID: 33868150 PMCID: PMC8044522 DOI: 10.3389/fneur.2021.645822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
Background: The optimal timing of anticoagulation after stroke in patients with atrial fibrillation (AF) is unknown. Aim and Hypothesis: Our primary aim is to demonstrate the safety of edoxaban initiation within 5 days of AF related stroke. Our secondary aim is to determine predictors of hemorrhagic transformation (HT) after AF related stroke. We hypothesize that the rate of radiological HT will not be increased in patients starting edoxaban within 5 days of AF related stroke, relative to those in whom initiation is delayed. We hypothesize that the risk of HT in patients treated with edoxaban can be predicted using RNA expressed in leukocytes at time of stroke. Methods and Design: LASER (Lixiana Acute Stroke Evaluation Registry) is a randomized controlled trial with an associated registry (clinicaltrials.gov NCT03494530). One hundred and fifty patients with ischemic stroke and AF will undergo baseline Computed Tomography (CT) scan and will be randomized 2:1 within 5 days of symptom onset to early (≤5 days, n = 100) or delayed (6–14 days, n = 50) edoxaban initiation. Participants will undergo clinical assessment and repeat CT at 7 days and clinical assessment at 90 days. Study Outcomes: The primary outcome is the rate of incident radiological HT. Secondary outcomes include symptomatic HT, recurrent ischemic stroke, recurrent sub-clinical infarcts on follow up CT, systemic hemorrhagic complication rate, National Institute of Health Stroke Scale and modified Rankin Scale at day 7 and 90, mortality within 90 days, quality of life assessments at day 90, and predictors of HT, including RNA expression by 6 pre-selected candidate genes. Discussion: Event rates for both HT and recurrent ischemic events, in patients treated with early vs. delayed edoxaban initiation are unknown. The primary study endpoint of LASER is an objective performance criterion relevant to clinical decision making in patients with AF related stroke. This study will provide data required for a definitive safety/efficacy study sample size power calculation.
Collapse
Affiliation(s)
- Anas Alrohimi
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Glen Jickling
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Khurshid Khan
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mahesh Kate
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Brian Buck
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ken Butcher
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
23
|
Cowan LT, Buck B, Schwind JS, Lutsey PL, Pankow JS, Matsushita K, Ishigami J, Lakshminarayan K. Triggering of cardiovascular disease by infection type: The Atherosclerosis Risk in Communities study (ARIC). Int J Cardiol 2021; 325:155-160. [PMID: 33031889 PMCID: PMC10031808 DOI: 10.1016/j.ijcard.2020.09.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 09/18/2020] [Accepted: 09/30/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute infections are known triggers of cardiovascular disease (CVD) but how this association varies across infection types is unknown. We hypothesized while acute infections increase CVD risk, the strength of this association varies across infection types. METHOD Acute coronary heart disease (CHD) and ischemic stroke cases were identified in the Atherosclerosis Risk in Communities Study (ARIC). ICD-9 codes from Medicare claims were used to identify cellulitis, pneumonia, urinary tract infections (UTI), and bloodstream infections. A case-crossover design and conditional logistic regression were used to compare infection types among acute CHD and stroke cases 14, 30, 42, and 90 days before the event with two corresponding control periods (1 and 2 years prior). RESULTS Of the 1312 acute CHD cases, 116 had a UTI, 102 had pneumonia, 43 had cellulitis, and 28 had a bloodstream infection 90 days before the CHD event. Pneumonia (OR = 25.53 (9.21,70.78)), UTI (OR = 3.32 (1.93, 5.71)), bloodstream infections (OR = 5.93 (2.07, 17.00)), and cellulitis (OR = 2.58 (1.09, 6.13)) were associated with higher acute CHD risk within 14 days of infection. Of the 727 ischemic stroke cases, 12 had cellulitis, 27 had pneumonia, 56 had a UTI, and 5 had a bloodstream infection within 90 days of the stroke. Pneumonia (OR = 5.59 (1.77, 17.67)) and UTI (OR = 3.16 (1.68, 5.94)) were associated with higher stroke risk within 14 days of infection. CONCLUSIONS Patients with pneumonia, UTI, or bloodstream infection appear to be at a 2.5 to 25.5 fold elevated CVD risk following infection. Preventive therapies during this high-risk period should be considered.
Collapse
Affiliation(s)
- Logan T Cowan
- Department of Biostatistics, Epidemiology, & Environmental Health Sciences, Georgia Southern University, PO Box 7989, Statesboro, GA 30460, United States of America.
| | - Brian Buck
- Department of Biostatistics, Epidemiology, & Environmental Health Sciences, Georgia Southern University, PO Box 7989, Statesboro, GA 30460, United States of America
| | - Jessica S Schwind
- Department of Biostatistics, Epidemiology, & Environmental Health Sciences, Georgia Southern University, PO Box 7989, Statesboro, GA 30460, United States of America
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, 300 West Bank Office Building 1300 S. 2nd St, Minneapolis, MN 55454, United States of America
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota, 300 West Bank Office Building 1300 S. 2nd St, Minneapolis, MN 55454, United States of America
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Suite 2-600, Baltimore, MD 21287, United States of America
| | - Junichi Ishigami
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Suite 2-600, Baltimore, MD 21287, United States of America
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, University of Minnesota, 300 West Bank Office Building 1300 S. 2nd St, Minneapolis, MN 55454, United States of America
| |
Collapse
|
24
|
Alrohimi A, Buck B, Jickling G, Shuaib A, Thirunavukkarasu S, Butcher KS. Early apixaban therapy after ischemic stroke in patients with atrial fibrillation. J Neurol 2021; 268:1837-1846. [PMID: 33392636 DOI: 10.1007/s00415-020-10335-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal timing of anticoagulation after stroke in patients with atrial fibrillation (AF) is unknown. We aimed to objectively assess the rate of radiological hemorrhagic transformation (HT) associated with early anticoagulation. PATIENTS AND METHODS A prospective, open label study (NCT04435418) of patients with AF treated with apixaban within 14 days of ischemic stroke/TIA onset was conducted. Baseline and follow-up CT scans were assessed for HT and graded using European Cooperative Acute Stroke Study (ECASS) criteria. The primary endpoint was symptomatic HT. Incident HT rates were assessed as Objective Performance Criteria. RESULTS One-hundred AF stroke patients, with a mean age of 79 ± 11 years were enrolled. Median infarct volume was 4 (0.5-10.75) ml. Median time from index event onset to apixaban initiation was 2 (1-6) days, and median baseline NIHSS was 4 (1-9). Asymptomatic HT on baseline imaging was present in 15 patients. Infarct volume (OR = 1.1, [1.02-1.12], p < 0.0001) and NIHSS (OR = 1.11, [1.03-1.20], p = 0.007) were both associated with baseline HT. No patients developed symptomatic HT or systemic hemorrhage. Incident asymptomatic HT was seen on follow-up CT scan in 3 patients. Patients with incident HT were functionally independent (mRS = 0-2) at 90 days. Recurrent ischemic events occurred within 90 days in 13 patients, 4 of which were associated with severe disability (mRS 3-5) and 4 with death. DISCUSSION Early apixaban treatment did not precipitate symptomatic HT after stroke. All HT was asymptomatic identified on imaging. Recurrent ischemic events were common and clinically symptomatic. CONCLUSIONS Symptomatic HT rates are likely to be low in randomized trials of DOAC initiation post-stroke. Recurrent ischemic stroke may be the major clinical outcome. These data may be used as expected event rates when calculating sample size requirements for future safety/efficacy trials of early versus late DOAC initiation after AF-related stroke.
Collapse
Affiliation(s)
- Anas Alrohimi
- University of Alberta, Medicine, Edmonton, Canada
- King Saud University, Medicine, Riyadh, Saudi Arabia
| | - Brian Buck
- University of Alberta, Medicine, Edmonton, Canada
| | | | | | | | - Ken S Butcher
- University of Alberta, Medicine, Edmonton, Canada.
- Prince of Wales Clinical School, University of New South Wales, Level 1, South Wing, Edmund Blacket Building, Sydney, Australia.
- Prince of Wales Hospital, Randwick, NSW, 2031, Australia.
| |
Collapse
|
25
|
Chew DS, Rennert-May E, Quinn FR, Buck B, Hill MD, Spackman E, Manns BJ, Exner DV. Economic evaluation of extended electrocardiogram monitoring for atrial fibrillation in patients with cryptogenic stroke. Int J Stroke 2020; 16:809-817. [PMID: 33232196 DOI: 10.1177/1747493020974561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Timely identification of occult atrial fibrillation following cryptogenic stroke facilitates consideration of oral anticoagulation therapy. Extended electrocardiography monitoring beyond 24 to 48 h Holter monitoring improves atrial fibrillation detection rates, yet uncertainty remains due to upfront costs and the projected long-term benefit. We sought to determine the cost-effectiveness of three electrocardiography monitoring strategies in detecting atrial fibrillation after cryptogenic stroke. METHODS A decision-analytic Markov model was used to project the costs and outcomes of three different electrocardiography monitoring strategies (i.e. 30-day electrocardiography monitoring, three-year implantable loop recorder monitoring, and conventional Holter monitoring) in acute stroke survivors without previously documented atrial fibrillation. RESULTS The lifetime discounted costs and quality-adjusted life years were $206,385 and 7.77 quality-adjusted life years for conventional monitoring, $207,080 and 7.79 quality-adjusted life years for 30-day extended electrocardiography monitoring, and $210,728 and 7.88 quality-adjusted life years for the implantable loop recorder strategy. Additional quality-adjusted life years could be attained at a more favorable incremental cost per quality-adjusted life year with the implantable loop recorder strategy, compared with the 30-day electrocardiography monitoring strategy, thereby eliminating the 30-day strategy by extended dominance. The implantable loop recorder strategy was associated with an incremental cost per quality-adjusted life year gained of $40,796 compared with conventional monitoring. One-way sensitivity analyses indicated that the model was most sensitive to the rate of recurrent ischemic stroke. CONCLUSIONS An implantable loop recorder strategy for detection of occult atrial fibrillation in patients with cryptogenic stroke is more economically attractive than 30-day electrocardiography monitoring compared to conventional monitoring and is associated with a cost per quality-adjusted life year gained in the range of other publicly funded therapies. The value proposition is improved when considering patients at the highest risk of recurrent ischemic stroke. However, the implantable loop recorder strategy is associated with increased health care costs, and the opportunity cost of wide scale implementation must be considered.
Collapse
Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.,Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Elissa Rennert-May
- Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Alberta, Canada
| | - F Russell Quinn
- Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Eldon Spackman
- Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Braden J Manns
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Derek V Exner
- Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
| |
Collapse
|
26
|
Zerna C, Rogers E, Rabi DM, Demchuk AM, Kamal N, Mann B, Jeerakathil T, Buck B, Shuaib A, Rempel J, Menon BK, Goyal M, Hill MD. Comparative Effectiveness of Endovascular Treatment for Acute Ischemic Stroke: A Population-Based Analysis. J Am Heart Assoc 2020; 9:e014541. [PMID: 32208827 PMCID: PMC7428615 DOI: 10.1161/jaha.119.014541] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background A heterogeneous patient population receives endovascular treatment (EVT) for acute ischemic stroke caused by proximal large-vessel occlusion every day. We aimed to conduct a population-based study of EVT in the province of Alberta, Canada, to understand the effectiveness in a complete population and how the magnitude of effect differs from the artificial world of clinical trials. Methods and Results Within a 3-year period (April 2015 to March 2018), 576 patients fit the inclusion criteria of our study and constituted the EVT group of our analysis. The medical treatment group of the ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT [Computed Tomography] to Recanalization Times) trial had 150 patients. Thus, our total sample size was 726. We captured outcomes in clinical routine using administrative data and a linked database method. Primary outcome of our study was home-time. Home-time refers to the number of days that the patient was back at premorbid living situation without increase in level of care within 90 days of index stroke event. Median age of patients was 70 years (interquartile range, 59-81 years), and 47.8% were women. Median National Institutes of Health Stroke Scale score was 17 (interquartile range, 13-20). EVT was associated with an increased 90-day home-time by an average of 8.5 days compared with medical treatment alone using Cragg hurdle regression (P=0.009). Age and higher National Institutes of Health Stroke Scale score were associated with decreased 90-day home-time (both P<0.001). Multivariable logistic regression showed no association between EVT and mortality at 90 days (odds ratio, 0.76; 95% CI, 0.47-1.24). Conclusions EVT for acute ischemic stroke caused by proximal large-vessel occlusion was effective in our province-wide population-based study and results in an increase of 90-day home-time by ~8.5 days.
Collapse
Affiliation(s)
- Charlotte Zerna
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Department of Community Health Sciences University of Calgary Alberta Canada
| | - Edwin Rogers
- Clinical Analytics Alberta Health Services Edmonton Alberta Canada
| | - Doreen M Rabi
- Department of Community Health Sciences University of Calgary Alberta Canada.,Department of Medicine Cumming School of Medicine University of Calgary Alberta Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Hotchkiss Brain Institute University of Calgary Alberta Canada.,Department of Radiology Cumming School of Medicine University of Calgary Alberta Canada
| | - Noreen Kamal
- Department of Industrial Engineering Dalhousie University Halifax Nova Scotia Canada
| | - Balraj Mann
- Cardiovascular Health and Stroke Strategic Clinical Network Alberta Health Services Edmonton Alberta Canada
| | - Tom Jeerakathil
- Division of Neurology Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Brian Buck
- Division of Neurology Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Ashfaq Shuaib
- Division of Neurology Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Jeremy Rempel
- Department of Radiology and Diagnostic Imaging University of Alberta Edmonton Alberta Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Hotchkiss Brain Institute University of Calgary Alberta Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Department of Radiology Cumming School of Medicine University of Calgary Alberta Canada
| | - Michael D Hill
- Department of Clinical Neurosciences Cumming School of Medicine University of Calgary Alberta Canada.,Hotchkiss Brain Institute University of Calgary Alberta Canada.,Department of Community Health Sciences University of Calgary Alberta Canada.,Department of Radiology Cumming School of Medicine University of Calgary Alberta Canada
| |
Collapse
|
27
|
Butcher KS, Ng K, Sheridan P, Field TS, Coutts SB, Siddiqui M, Gioia LC, Buck B, Hill MD, Miller J, Klahr AC, Sivakumar L, Benavente OR, Hart RG, Sharma M. Dabigatran Treatment of Acute Noncardioembolic Ischemic Stroke. Stroke 2020; 51:1190-1198. [PMID: 32098609 DOI: 10.1161/strokeaha.119.027569] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Patients with transient ischemic attack (TIA) and minor ischemic stroke are at risk for early recurrent cerebral ischemia. Anticoagulants are associated with reduced recurrence but also increased hemorrhagic transformation (HT). The safety of the novel oral anticoagulant dabigatran in acute stroke has not been evaluated. Methods- DATAS II (Dabigatran Treatment of Acute Stroke II) was a phase II prospective, randomized open label, blinded end point trial. Patients with noncardioembolic stroke/transient ischemic attack (National Institutes of Health Stroke Scale score, ≤9; infarct volume, ≤25 mL) were randomized to dabigatran or aspirin. Magnetic resonance imaging was performed before randomization and repeated at day 30. Imaging end points were ascertained centrally by readers blinded to treatment. The primary end point was symptomatic HT within 37 days of randomization. Results- A total of 305 patients, mean age 66.59±13.21 years, were randomized to dabigatran or aspirin a mean of 42.00±17.31 hours after symptom onset. The qualifying event was a transient ischemic attack in 21%, and ischemic stroke in 79% of patients. Median National Institutes of Health Stroke Scale (interquartile range) was 1 (0-2), and mean infarct volume 3.2±6.5 mL. No symptomatic HT occurred. Asymptomatic petechial HT developed in 11/142 (7.8%) of dabigatran-assigned patients and 5/142 (3.5%) of aspirin-assigned patients (relative risk, 2.301 [95% CI, 0.778-6.802]). Baseline infarct volume predicted incident HT (odds ratio, 1.07 [95% CI, 1.03-1.12]; P=0.0026). Incident covert infarcts on day 30 imaging occurred in 9/142 (6.3%) of dabigatran-assigned and 14/142 (9.8%) of aspirin-assigned patients (relative risk, 0.62 [95% CI, 0.26, 1.48]). Conclusions- Dabigatran was associated with a risk of HT similar to aspirin in acute minor noncardioembolic ischemic stroke/transient ischemic attack. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02295826.
Collapse
Affiliation(s)
- Ken S Butcher
- From the Division of Neurology, University of Alberta, Edmonton, Canada (K.S.B., A.C.K., B.B., L.S., M.S.).,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (K.S.B.)
| | - Kelvin Ng
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada (M.S., K.N., J.M., T.S.F., J.M., R.G.H)
| | | | - Thalia S Field
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada (M.S., K.N., J.M., T.S.F., J.M., R.G.H).,University of British Columbia, Vancouver, Canada (T.S.F., O.R.B.)
| | - Shelagh B Coutts
- Department of Clinical Neuroscience, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, AB, Canada (S.B.C., M.D.H.)
| | - Muzzafar Siddiqui
- From the Division of Neurology, University of Alberta, Edmonton, Canada (K.S.B., A.C.K., B.B., L.S., M.S.)
| | | | - Brian Buck
- From the Division of Neurology, University of Alberta, Edmonton, Canada (K.S.B., A.C.K., B.B., L.S., M.S.)
| | - Michael D Hill
- Department of Clinical Neuroscience, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, AB, Canada (S.B.C., M.D.H.)
| | - Jodi Miller
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada (M.S., K.N., J.M., T.S.F., J.M., R.G.H)
| | - Ana C Klahr
- From the Division of Neurology, University of Alberta, Edmonton, Canada (K.S.B., A.C.K., B.B., L.S., M.S.)
| | - Leka Sivakumar
- From the Division of Neurology, University of Alberta, Edmonton, Canada (K.S.B., A.C.K., B.B., L.S., M.S.)
| | | | - Robert G Hart
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada (M.S., K.N., J.M., T.S.F., J.M., R.G.H)
| | - Mike Sharma
- From the Division of Neurology, University of Alberta, Edmonton, Canada (K.S.B., A.C.K., B.B., L.S., M.S.).,Population Health Research Institute, McMaster University, Hamilton, ON, Canada (M.S., K.N., J.M., T.S.F., J.M., R.G.H)
| |
Collapse
|
28
|
Zerna C, Rogers E, Rabi DM, Demchuk AM, Kamal N, Mann B, Jeerakathil T, Buck B, Shuaib A, Rempel J, Menon BK, Goyal M, Hill MD. Abstract TP39: Comparative Effectiveness of Endovascular Treatment for Acute Ischemic Stroke: A Population-Based Analysis. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tp39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
A heterogeneous patient population receives endovascular treatment (EVT) for acute ischemic stroke due to proximal large vessel occlusion every day. We aimed to conduct a population-based study of EVT in the province of Alberta, Canada, to understand the effectiveness in a complete population and how the magnitude of effect differs from the artificial world of clinical trials.
Methods and Results:
Within a three year period (April 2015 - March 2018), 576 patients fit the inclusion criteria of our study and constituted the EVT group of our analysis. The medical treatment group of the ESCAPE trial had 150 patients. Thus our total sample size was 726. We captured outcomes in clinical routine using administrative data and a linked database methodology. Primary outcome of our study was home-time. Home-time refers to the number of days that the patient was back at pre-morbid living situation without increase in level of care within 90 days of index stroke event. Median age of patients was 70 years (interquartile range (IQR) 59 - 81) and 47.8% were female. Median National Institutes of Health Stroke Scale (NIHSS) score was 17 (IQR 13 - 20). EVT was associated with an increased 90-day home-time by an average of 8.5 days compared to medical treatment alone using Cragg hurdle regression (p = 0.009). Age and higher NIHSS score were associated with decreased 90-day home-time (both p = 0.001). Multivariable logistic regression showed no association between EVT and mortality at 90 days (odds ratio 0.76, 95% confidence interval 0.47 - 1.24).
Conclusions:
EVT for acute ischemic stroke due to proximal large vessel occlusion was effective in our province-wide population-based study and results in increased 90-day home-time by ~8.5 days. Home-time is a novel and patient-centered outcome that reflects health circumstances that are easy to understand and meaningful to patients and their caregivers.
Collapse
|
29
|
Buck B, Muniz-Rodriguez K, Jillson S, Huang LT, Adhikari A, Jacob N, Wei Y, Zhang J. Pet ownership and risk of dying from cancer: observation from a nationally representative cohort. Int J Environ Health Res 2020; 30:105-116. [PMID: 30758233 DOI: 10.1080/09603123.2019.1577366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 01/26/2019] [Indexed: 06/09/2023]
Abstract
We longitudinally examined the relationship between pet ownership and risk of dying from cancer in a nationally representative cohort of 13,725 adults in the Third National Health and Nutrition Examination Survey, 1988-1994. The vital status was followed through 31 December 2010. Women who owned pets (any type) presented one-year shorter survival time (15.88 years) than non-pet owner (16.83 years). A larger difference of survival time was particularly seen in bird owners (13.01 years) compared to non-bird owners (16.82 years). After adjusting for potential confounders, hazard ratio (HR) of dying from cancer associated with any type of pets was 1.08 (95% CI = 0.77-1.50) for men and 1.40 (1.01-1.93) for women. The association in women was presumably driven by owning birds [HR 2.41 (1.34-4.31)] or cats [HR 1.48 (0.97-2.24)]. Keeping birds and cats in the household was associated with an increased risk of dying from cancer, especially in women.
Collapse
Affiliation(s)
- Brian Buck
- Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| | - Kamalich Muniz-Rodriguez
- Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| | - Sarah Jillson
- Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| | - Li-Ting Huang
- Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| | - Atin Adhikari
- Department of Environmental Health Sciences, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| | - Naduparambil Jacob
- Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Yudan Wei
- Department of Community Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Jian Zhang
- Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| |
Collapse
|
30
|
Kate M, Asdaghi N, Gioia LC, Buck B, Majumdar SR, Jeerakathil T, Shuaib A, Emery D, Beaulieu C, Butcher K. Blood pressure reduction in hypertensive acute ischemic stroke patients does not affect cerebral blood flow. J Cereb Blood Flow Metab 2019; 39:1878-1887. [PMID: 29737226 PMCID: PMC6727146 DOI: 10.1177/0271678x18774708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The effect of blood pressure (BP) reduction on cerebral blood flow (CBF) in acute ischemic stroke is unknown. We measured regional CBF with perfusion-weighted MRI before and after BP treatment in a three-armed non-randomized prospective controlled trial. Treatment arm assignment was based on acute mean arterial pressure (MAP). Patients with (MAP) >120 mmHg (n = 14) were treated with intravenous labetalol and sublingual (SL) nitroglycerin (labetalol group). Those with MAP 100-120 mmHg (n = 17) were treated with SL nitroglycerin (0.3 mg) ('NTG Group') and those with baseline MAP<100 mmHg (n = 18) were not treated with antihypertensive drugs (untreated group). Forty-nine patients (18 female, mean age 65.3 ± 12.9 years) were serially imaged. Labetalol reduced MAP by 12.5 (5.7-17.7) mmHg, p = 0.0002. MAP remained stable in the NTG (6.0 (0.4-16, p = 0.3) mmHg and untreated groups (-0.3 (-2.3-7.0, p = 0.2) mmHg. The volume of total hypoperfused tissue (CBF<18 ml/100 g/min) did not increase after labetalol (-1.1 ((-6.5)-(-0.2)) ml, p = 0.1), NTG (0 ((-1.5)-4.5) ml, p = 0.72), or no treatment 0.25 ((-10.1)-4.5) ml, p = 0.87). Antihypertensive therapy, based on presenting BP, in acute stroke patients was not associated with an increased volume of total hypoperfused tissue.
Collapse
Affiliation(s)
- Mahesh Kate
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| | - Negar Asdaghi
- 2 Department of Neurology, University of Miami, Miami, FL, USA
| | - Laura C Gioia
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| | - Brian Buck
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| | - Sumit R Majumdar
- 3 Department of Medicine, Division of General Internal Medicine, University of Alberta, Edmonton, Canada
| | | | - Ashfaq Shuaib
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| | - Derek Emery
- 4 Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | - Christian Beaulieu
- 5 Department of Biomedical Engineering, University of Alberta, Edmonton, Canada
| | - Kenneth Butcher
- 1 Division of Neurology, University of Alberta, Edmonton, Canada
| |
Collapse
|
31
|
Abstract
Background and Purpose- Cerebral perfusion in acute ischemic stroke patients is often assessed before endovascular thrombectomy (EVT), but rarely after. Perfusion data obtained following EVT may provide additional prognostic information. We developed a tool to quantitatively derive perfusion measurements from digital subtraction angiography (DSA) data and examined perfusion in patients following EVT. Methods- Source DSA images from acute anterior circulation stroke patients undergoing EVT were retrospectively assessed. Following deconvolution, maps of mean transit time (MTT) were generated from post-EVT DSA source data. Thrombolysis in Cerebral Infarction grades and MTT in patients with and without hemorrhagic transformation (HT) at 24 hours were compared. Receiver operating characteristic modeling was used to classify the presence/absence of HT at 24 hours by MTT. Results- Perfusion maps were generated in 50 patients using DSA acquisitions that were a median (interquartile range) of 9 (8-10) seconds in duration. The median post-EVT MTT within the affected territory was 2.6 (2.2-3.3) seconds. HT was observed on follow-up computed tomography in 16 (32%) patients. Thrombolysis in Cerebral Infarction grades did not differ in patients with HT from those without (P=0.575). Post-EVT MTT maps demonstrated focal areas of hyperperfusion (n=8) or persisting hypoperfusion (n=3) corresponding to the regions where HT later developed. The relationship between MTT and HT was U-shaped; HT occurred in patients at both the lowest and highest extremes of MTT. An MTT threshold <2 or >4 seconds was 81% sensitive and 94% specific for classifying the presence of HT at follow-up. Conclusions- Perfusion measurements can be obtained using DSA perfusion with minimal changes to current stroke protocols. Perfusion imaging post-recanalization may have additional clinical utility beyond visual assessment of source angiographic images alone.
Collapse
Affiliation(s)
- Jayme C Kosior
- From the Division of Neurology (J.C.K, B.B., R.W., N.A.L., K.B.), University of Alberta, Edmonton, Canada
| | - Brian Buck
- From the Division of Neurology (J.C.K, B.B., R.W., N.A.L., K.B.), University of Alberta, Edmonton, Canada
| | - Robert Wannamaker
- From the Division of Neurology (J.C.K, B.B., R.W., N.A.L., K.B.), University of Alberta, Edmonton, Canada
| | - Mahesh Kate
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (M.K.)
| | - Natalia A Liapounova
- From the Division of Neurology (J.C.K, B.B., R.W., N.A.L., K.B.), University of Alberta, Edmonton, Canada
| | - Jeremy L Rempel
- Department of Radiology and Diagnostic Imaging (J.L.R.), University of Alberta, Edmonton, Canada
| | - Kenneth Butcher
- From the Division of Neurology (J.C.K, B.B., R.W., N.A.L., K.B.), University of Alberta, Edmonton, Canada.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia (K.B.)
| |
Collapse
|
32
|
Klahr AC, Kate M, Kosior J, Buck B, Shuaib A, Emery D, Butcher K. Early hematoma retraction in intracerebral hemorrhage is uncommon and does not predict outcome. PLoS One 2018; 13:e0205436. [PMID: 30300383 PMCID: PMC6177160 DOI: 10.1371/journal.pone.0205436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
Background Clot retraction in intracerebral hemorrhage (ICH) has been described and postulated to be related to effective hemostasis and perihematoma edema (PHE) formation. The incidence and quantitative extent of hematoma retraction (HR) is unknown. Our aim was to determine the incidence of HR between baseline and time of admission. We also tested the hypothesis that patients with HR had higher PHE volume and good prognosis. Methods This was a retrospective single-centre study in which serial planimetric volume measurements of the total hematoma volume (parenchymal (IPH) and intraventricular (IVH)) and PHE were performed in ICH patients with baseline non-contrast computed tomography (CT) completed within 6 hours of onset and follow-up CT 24 (±12) hours from symptom onset. HR was defined as a decrease in volume of >3ml or >15%, and hematoma expansion (HE) as an increase of >6ml or >30%. All other patients were categorized as stable hematoma (HS). Good outcome was defined as modified Rankin Scale (mRS) 0–2 at 90 days. Results A total of 136 patients (mean age = 69.3±13.39 years, 58.1% male) were included. Median (interquartile range) baseline total hematoma volume was 14.96 (7.80, 31.88) ml. HR >3ml and >15% occurred in 6 (4.4%) and 8 (5.9%) patients, respectively. Neither definition of HR was associated with follow-up PHE (p>0.297) or good outcome (p>0.249). IVH was the only independent predictor of HR (p<0.0241). Conclusions Early HR is rare and associated with IVH, but not with PHE or clinical outcome. There was no relationship between HR, PHE, and patient prognosis. Therefore, HR is unlikely to be a useful endpoint in clinical ICH studies.
Collapse
Affiliation(s)
- Ana C. Klahr
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Mahesh Kate
- Department of Neurology, Christian Medical College Ludhiana, Ludhiāna, India
| | - Jayme Kosior
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Derek Emery
- Department of Radiology, University of Alberta, Edmonton, Canada
| | - Kenneth Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
- * E-mail:
| |
Collapse
|
33
|
Neves Briard J, Zewude RT, Kate MP, Rowe BH, Buck B, Butcher K, Gioia LC. Stroke Mimics Transported by Emergency Medical Services to a Comprehensive Stroke Center: The Magnitude of the Problem. J Stroke Cerebrovasc Dis 2018; 27:2738-2745. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/22/2018] [Accepted: 05/28/2018] [Indexed: 11/29/2022] Open
|
34
|
Román LS, Menon BK, Blasco J, Hernández-Pérez M, Dávalos A, Majoie CBLM, Campbell BCV, Guillemin F, Lingsma H, Anxionnat R, Epstein J, Saver JL, Marquering H, Wong JH, Lopes D, Reimann G, Desal H, Dippel DWJ, Coutts S, du Mesnil de Rochemont R, Yavagal D, Ferre JC, Roos YBWEM, Liebeskind DS, Lenthall R, Molina C, Al Ajlan FS, Reddy V, Dowlatshahi D, Sourour NA, Oppenheim C, Mitha AP, Davis SM, Weimar C, van Oostenbrugge RJ, Cobo E, Kleinig TJ, Donnan GA, van der Lugt A, Demchuk AM, Berkhemer OA, Boers AMM, Ford GA, Muir KW, Brown BS, Jovin T, van Zwam WH, Mitchell PJ, Hill MD, White P, Bracard S, Goyal M, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle J, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach Z, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S, Wakhloo A, Moonis M, Henniger N, Goddeau R, van den Berg R, Massari F, Minaeian A, Lozano JD, Ramzan M, Stout C, Patel A, Tunguturi A, Onteddu S, Carandang R, Howk M, Koudstaal PJ, Ribó M, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Meler P, Huerga E, Gelabert S, Coscojuela P, van Zwam WH, Tomasello A, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Rovira A, Molina CA, Millán M, Muñoz L, Roos YB, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, García Bermejo P, Remollo S, Castaño C, García-Sort R, van der Lugt A, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Dávalos A, Chamorro A, Urra X, Obach V, van Oostenbrugge RJ, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Ariño H, Aceituno A, Rudilosso S, Renu A, Majoie CB, Macho JM, San Roman L, Blasco J, López A, Macías N, Cardona P, Quesada H, Rubio F, Cano L, Lara B, Dippel DW, de Miquel MA, Aja L, Serena J, Cobo E, Albers GW, Lees KR, Arenillas J, Roberts R, Minhas P, Al-Ajlan F, Brown MM, Salluzzi M, Zimmel L, Patel S, Eesa M, Martí-Fàbregas J, Jankowitz B, Serena J, Salvat-Plana M, López-Cancio E, Bracard S, Liebig T, Ducrocq X, Anxionnat R, Baillot PA, Barbier C, Derelle AL, Lacour JC, Richard S, Samson Y, Sourour N, Baronnet-Chauvet F, Stijnen T, Clarencon F, Crozier S, Deltour S, Di Maria F, Le Bouc R, Leger A, Mutlu G, Rosso C, Szatmary Z, Yger M, Andersson T, Zavanone C, Bakchine S, Pierot L, Caucheteux N, Estrade L, Kadziolka K, Leautaud A, Renkes C, Serre I, Desal H, Mattle H, Guillon B, Boutoleau-Bretonniere C, Daumas-Duport B, De Gaalon S, Derkinderen P, Evain S, Herisson F, Laplaud DA, Lebouvier T, Lintia-Gaultier A, Wahlgren N, Pouclet-Courtemanche H, Rouaud T, Rouaud Jaffrenou V, Schunck A, Sevin-Allouet M, Toulgoat F, Wiertlewski S, Gauvrit JY, Ronziere T, Cahagne V, van der Heijden E, Ferre JC, Pinel JF, Raoult H, Mas JL, Meder JF, Al Najjar-Carpentier AA, Birchenall J, Bodiguel E, Calvet D, Domigo V, Ghannouti N, Godon-Hardy S, Guiraud V, Lamy C, Majhadi L, Morin L, Naggara O, Trystram D, Turc G, Berge J, Sibon I, Fleitour N, Menegon P, Barreau X, Rouanet F, Debruxelles S, Kazadi A, Renou P, Fleury O, Pasco-Papon A, Dubas F, Caroff J, Hooijenga I, Godard Ducceschi S, Hamon MA, Lecluse A, Marc G, Giroud M, Ricolfi F, Bejot Y, Chavent A, Gentil A, Kazemi A, Puppels C, Osseby GV, Voguet C, Mahagne MH, Sedat J, Chau Y, Suissa L, Lachaud S, Houdart E, Stapf C, Buffon Porcher F, Pellikaan W, Chabriat H, Guedin P, Herve D, Jouvent E, Mawet J, Saint-Maurice JP, Schneble HM, Turjman F, Nighoghossian N, Berhoune NN, Geerling A, Bouhour F, Cho TH, Derex L, Felix S, Gervais-Bernard H, Gory B, Manera L, Mechtouff L, Ritzenthaler T, Riva R, Lindl-Velema A, Salaris Silvio F, Tilikete C, Blanc R, Obadia M, Bartolini MB, Gueguen A, Piotin M, Pistocchi S, Redjem H, Drouineau J, van Vemde G, Neau JP, Godeneche G, Lamy M, Marsac E, Velasco S, Clavelou P, Chabert E, Bourgois N, Cornut-Chauvinc C, Ferrier A, de Ridder A, Gabrillargues J, Jean B, Marques AR, Vitello N, Detante O, Barbieux M, Boubagra K, Favre Wiki I, Garambois K, Tahon F, Greebe P, Ashok V, Voguet C, Coskun O, Guedin P, Rodesch G, Lapergue B, Bourdain F, Evrard S, Graveleau P, Decroix JP, de Bont-Stikkelbroeck J, Wang A, Sellal F, Ahle G, Carelli G, Dugay MH, Gaultier C, Lebedinsky AP, Lita L, Musacchio RM, Renglewicz-Destuynder C, de Meris J, Tournade A, Vuillemet F, Montoro FM, Mounayer C, Faugeras F, Gimenez L, Labach C, Lautrette G, Denier C, Saliou G, Janssen K, Chassin O, Dussaule C, Melki E, Ozanne A, Puccinelli F, Sachet M, Sarov M, Bonneville JF, Moulin T, Biondi A, Struijk W, De Bustos Medeiros E, Vuillier F, Courtheoux P, Viader F, Apoil-Brissard M, Bataille M, Bonnet AL, Cogez J, Kazemi A, Touze E, Licher S, Leclerc X, Leys D, Aggour M, Aguettaz P, Bodenant M, Cordonnier C, Deplanque D, Girot M, Henon H, Kalsoum E, Boodt N, Lucas C, Pruvo JP, Zuniga P, Bonafé A, Arquizan C, Costalat V, Machi P, Mourand I, Riquelme C, Bounolleau P, Ros A, Arteaga C, Faivre A, Bintner M, Tournebize P, Charlin C, Darcel F, Gauthier-Lasalarie P, Jeremenko M, Mouton S, Zerlauth JB, Venema E, Lamy C, Hervé D, Hassan H, Gaston A, Barral FG, Garnier P, Beaujeux R, Wolff V, Herbreteau D, Debiais S, Slokkers I, Murray A, Ford G, Muir KW, White P, Brown MM, Clifton A, Freeman J, Ford I, Markus H, Wardlaw J, Ganpat RJ, Lees KR, Molyneux A, Robinson T, Lewis S, Norrie J, Robertson F, Perry R, Dixit A, Cloud G, Clifton A, Mulder M, Madigan J, Roffe C, Nayak S, Lobotesis K, Smith C, Herwadkar A, Kandasamy N, Goddard T, Bamford J, Subramanian G, Saiedie N, Lenthall R, Littleton E, Lamin S, Storey K, Ghatala R, Banaras A, Aeron-Thomas J, Hazel B, Maguire H, Veraque E, Heshmatollah A, Harrison L, Keshvara R, Cunningham J, Schipperen S, Vinken S, van Boxtel T, Koets J, Boers M, Santos E, Borst J, Jansen I, Kappelhof M, Lucas M, Geuskens R, Barros RS, Dobbe R, Csizmadia M, Hill MD, Goyal M, Demchuk AM, Menon BK, Eesa M, Ryckborst KJ, Wright MR, Kamal NR, Andersen L, Randhawa PA, Stewart T, Patil S, Minhas P, Almekhlafi M, Mishra S, Clement F, Sajobi T, Shuaib A, Montanera WJ, Roy D, Silver FL, Jovin TG, Frei DF, Sapkota B, Rempel JL, Thornton J, Williams D, Tampieri D, Poppe AY, Dowlatshahi D, Wong JH, Mitha AP, Subramaniam S, Hull G, Lowerison MW, Sajobi T, Salluzzi M, Wright MR, Maxwell M, Lacusta S, Drupals E, Armitage K, Barber PA, Smith EE, Morrish WF, Coutts SB, Derdeyn C, Demaerschalk B, Yavagal D, Martin R, Brant R, Yu Y, Willinsky RA, Montanera WJ, Weill A, Kenney C, Aram H, Stewart T, Stys PK, Watson TW, Klein G, Pearson D, Couillard P, Trivedi A, Singh D, Klourfeld E, Imoukhuede O, Nikneshan D, Blayney S, Reddy R, Choi P, Horton M, Musuka T, Dubuc V, Field TS, Desai J, Adatia S, Alseraya A, Nambiar V, van Dijk R, Wong JH, Mitha AP, Morrish WF, Eesa M, Newcommon NJ, Shuaib A, Schwindt B, Butcher KS, Jeerakathil T, Buck B, Khan K, Naik SS, Emery DJ, Owen RJ, Kotylak TB, Ashforth RA, Yeo TA, McNally D, Siddiqui M, Saqqur M, Hussain D, Kalashyan H, Manosalva A, Kate M, Gioia L, Hasan S, Mohammad A, Muratoglu M, Williams D, Thornton J, Cullen A, Brennan P, O'Hare A, Looby S, Hyland D, Duff S, McCusker M, Hallinan B, Lee S, McCormack J, Moore A, O'Connor M, Donegan C, Brewer L, Martin A, Murphy S, O'Rourke K, Smyth S, Kelly P, Lynch T, Daly T, O'Brien P, O'Driscoll A, Martin M, Daly T, Collins R, Coughlan T, McCabe D, Murphy S, O'Neill D, Mulroy M, Lynch O, Walsh T, O'Donnell M, Galvin T, Harbison J, McElwaine P, Mulpeter K, McLoughlin C, Reardon M, Harkin E, Dolan E, Watts M, Cunningham N, Fallon C, Gallagher S, Cotter P, Crowe M, Doyle R, Noone I, Lapierre M, Coté VA, Lanthier S, Odier C, Durocher A, Raymond J, Weill A, Daneault N, Deschaintre Y, Jankowitz B, Baxendell L, Massaro L, Jackson-Graves C, Decesare S, Porter P, Armbruster K, Adams A, Billigan J, Oakley J, Ducruet A, Jadhav A, Giurgiutiu DV, Aghaebrahim A, Reddy V, Hammer M, Starr M, Totoraitis V, Wechsler L, Streib S, Rangaraju S, Campbell D, Rocha M, Gulati D, Silver FL, Krings T, Kalman L, Cayley A, Williams J, Stewart T, Wiegner R, Casaubon LK, Jaigobin C, del Campo JM, Elamin E, Schaafsma JD, Willinsky RA, Agid R, Farb R, ter Brugge K, Sapkoda BL, Baxter BW, Barton K, Knox A, Porter A, Sirelkhatim A, Devlin T, Dellinger C, Pitiyanuvath N, Patterson J, Nichols J, Quarfordt S, Calvert J, Hawk H, Fanale C, Frei DF, Bitner A, Novak A, Huddle D, Bellon R, Loy D, Wagner J, Chang I, Lampe E, Spencer B, Pratt R, Bartt R, Shine S, Dooley G, Nguyen T, Whaley M, McCarthy K, Teitelbaum J, Tampieri D, Poon W, Campbell N, Cortes M, Dowlatshahi D, Lum C, Shamloul R, Robert S, Stotts G, Shamy M, Steffenhagen N, Blacquiere D, Hogan M, AlHazzaa M, Basir G, Lesiuk H, Iancu D, Santos M, Choe H, Weisman DC, Jonczak K, Blue-Schaller A, Shah Q, MacKenzie L, Klein B, Kulandaivel K, Kozak O, Gzesh DJ, Harris LJ, Khoury JS, Mandzia J, Pelz D, Crann S, Fleming L, Hesser K, Beauchamp B, Amato-Marzialli B, Boulton M, Lopez-Ojeda P, Sharma M, Lownie S, Chan R, Swartz R, Howard P, Golob D, Gladstone D, Boyle K, Boulos M, Hopyan J, Yang V, Da Costa L, Holmstedt CA, Turk AS, Navarro R, Jauch E, Ozark S, Turner R, Phillips S, Shankar J, Jarrett J, Gubitz G, Maloney W, Vandorpe R, Schmidt M, Heidenreich J, Hunter G, Kelly M, Whelan R, Peeling L, Burns PA, Hunter A, Wiggam I, Kerr E, Watt M, Fulton A, Gordon P, Rennie I, Flynn P, Smyth G, O'Leary S, Gentile N, Linares G, McNelis P, Erkmen K, Katz P, Azizi A, Weaver M, Jungreis C, Faro S, Shah P, Reimer H, Kalugdan V, Saposnik G, Bharatha A, Li Y, Kostyrko P, Santos M, Marotta T, Montanera W, Sarma D, Selchen D, Spears J, Heo JH, Jeong K, Kim DJ, Kim BM, Kim YD, Song D, Lee KJ, Yoo J, Bang OY, Rho S, Lee J, Jeon P, Kim KH, Cha J, Kim SJ, Ryoo S, Lee MJ, Sohn SI, Kim CH, Ryu HG, Hong JH, Chang HW, Lee CY, Rha J, Davis SM, Donnan GA, Campbell BCV, Mitchell PJ, Churilov L, Yan B, Dowling R, Yassi N, Oxley TJ, Wu TY, Silver G, McDonald A, McCoy R, Kleinig TJ, Scroop R, Dewey HM, Simpson M, Brooks M, Coulton B, Krause M, Harrington TJ, Steinfort B, Faulder K, Priglinger M, Day S, Phan T, Chong W, Holt M, Chandra RV, Ma H, Young D, Wong K, Wijeratne T, Tu H, Mackay E, Celestino S, Bladin CF, Loh PS, Gilligan A, Ross Z, Coote S, Frost T, Parsons MW, Miteff F, Levi CR, Ang T, Spratt N, Kaauwai L, Badve M, Rice H, de Villiers L, Barber PA, McGuinness B, Hope A, Moriarty M, Bennett P, Wong A, Coulthard A, Lee A, Jannes J, Field D, Sharma G, Salinas S, Cowley E, Snow B, Kolbe J, Stark R, King J, Macdonnell R, Attia J, D'Este C, Saver JL, Goyal M, Diener HC, Levy EI, Bonafé A, Mendes Pereira V, Jahan R, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, von Kummer R, Smith W, Turjman F, Hamilton S, Chiacchierini R, Amar A, Sanossian N, Loh Y, Devlin T, Baxter B, Hawk H, Sapkota B, Quarfordt S, Sirelkhatim A, Dellinger C, Barton K, Reddy VK, Ducruet A, Jadhav A, Horev A, Giurgiutiu DV, Totoraitis V, Hammer M, Jankowitz B, Wechsler L, Rocha M, Gulati D, Campbell D, Star M, Baxendell L, Oakley J, Siddiqui A, Hopkins LN, Snyder K, Sawyer R, Hall S, Costalat V, Riquelme C, Machi P, Omer E, Arquizan C, Mourand I, Charif M, Ayrignac X, Menjot de Champfleur N, Leboucq N, Gascou G, Moynier M, du Mesnil de Rochemont R, Singer O, Berkefeld J, Foerch C, Lorenz M, Pfeilschifer W, Hattingen E, Wagner M, You SJ, Lescher S, Braun H, Dehkharghani S, Belagaje SR, Anderson A, Lima A, Obideen M, Haussen D, Dharia R, Frankel M, Patel V, Owada K, Saad A, Amerson L, Horn C, Doppelheuer S, Schindler K, Lopes DK, Chen M, Moftakhar R, Anton C, Smreczak M, Carpenter JS, Boo S, Rai A, Roberts T, Tarabishy A, Gutmann L, Brooks C, Brick J, Domico J, Reimann G, Hinrichs K, Becker M, Heiss E, Selle C, Witteler A, Al-Boutros S, Danch MJ, Ranft A, Rohde S, Burg K, Weimar C, Zegarac V, Hartmann C, Schlamann M, Göricke S, Ringlestein A, Wanke I, Mönninghoff C, Dietzold M, Budzik R, Davis T, Eubank G, Hicks WJ, Pema P, Vora N, Mejilla J, Taylor M, Clark W, Rontal A, Fields J, Peterson B, Nesbit G, Lutsep H, Bozorgchami H, Priest R, Ologuntoye O, Barnwell S, Dogan A, Herrick K, Takahasi C, Beadell N, Brown B, Jamieson S, Hussain MS, Russman A, Hui F, Wisco D, Uchino K, Khawaja Z, Katzan I, Toth G, Cheng-Ching E, Bain M, Man S, Farrag A, George P, John S, Shankar L, Drofa A, Dahlgren R, Bauer A, Itreat A, Taqui A, Cerejo R, Richmond A, Ringleb P, Bendszus M, Möhlenbruch M, Reiff T, Amiri H, Purrucker J, Herweh C, Pham M, Menn O, Ludwig I, Acosta I, Villar C, Morgan W, Sombutmai C, Hellinger F, Allen E, Bellew M, Gandhi R, Bonwit E, Aly J, Ecker RD, Seder D, Morris J, Skaletsky M, Belden J, Baker C, Connolly LS, Papanagiotou P, Roth C, Kastrup A, Politi M, Brunner F, Alexandrou M, Merdivan H, Ramsey C, Given II C, Renfrow S, Deshmukh V, Sasadeusz K, Vincent F, Thiesing JT, Putnam J, Bhatt A, Kansara A, Caceves D, Lowenkopf T, Yanase L, Zurasky J, Dancer S, Freeman B, Scheibe-Mirek T, Robison J, Rontal A, Roll J, Clark D, Rodriguez M, Fitzsimmons BFM, Zaidat O, Lynch JR, Lazzaro M, Larson T, Padmore L, Das E, Farrow-Schmidt A, Hassan A, Tekle W, Cate C, Jansen O, Cnyrim C, Wodarg F, Wiese C, Binder A, Riedel C, Rohr A, Lang N, Laufs H, Krieter S, Remonda L, Diepers M, Añon J, Nedeltchev K, Kahles T, Biethahn S, Lindner M, Chang V, Gächter C, Esperon C, Guglielmetti M, Arenillas Lara JF, Martínez Galdámez M, Calleja Sanz AI, Cortijo Garcia E, Garcia Bermejo P, Perez S, Mulero Carrillo P, Crespo Vallejo E, Ruiz Piñero M, Lopez Mesonero L, Reyes Muñoz FJ, Brekenfeld C, Buhk JH, Krützelmann A, Thomalla G, Cheng B, Beck C, Hoppe J, Goebell E, Holst B, Grzyska U, Wortmann G, Starkman S, Duckwiler G, Jahan R, Rao N, Sheth S, Ng K, Noorian A, Szeder V, Nour M, McManus M, Huang J, Tarpley J, Tateshima S, Gonzalez N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D. Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 2018; 17:895-904. [DOI: 10.1016/s1474-4422(18)30242-4] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022]
|
35
|
Kate M, Wannamaker R, Kamble H, Riaz P, Gioia LC, Buck B, Jeerakathil T, Smyth P, Shuaib A, Emery D, Butcher K. Penumbral Imaging-Based Thrombolysis with Tenecteplase Is Feasible up to 24 Hours after Symptom Onset. J Stroke 2018; 20:415. [PMID: 30121972 PMCID: PMC6186918 DOI: 10.5853/jos.2017.00178.e1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mahesh Kate
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Robert Wannamaker
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Harsha Kamble
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Parnian Riaz
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Laura C Gioia
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Penelope Smyth
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Derek Emery
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Kenneth Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
36
|
Buck B, Guha A, Arora S, Awan F, Lopez-Mattei JC, Plana Gomez JC, Oliveira G, Fradley M, Addison D. 6137Cancer patients have worse outcomes and undergo fewer procedures following in-hospital cardiac arrest than patients without comorbid cancer. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.6137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- B Buck
- The Ohio State University, Department of Internal Medicine, Columbus, United States of America
| | - A Guha
- The Ohio State University, Internal Medicine, Division of Cardiovascular Medicine, Columbus, United States of America
| | - S Arora
- University of North Carolina Hospitals, Department of Internal Medicine, Division of Cardiovascular Medicine, Chapel Hill, United States of America
| | - F Awan
- The Ohio State University, Department of Internal Medicine, Division of Hematology, Columbus, United States of America
| | - J C Lopez-Mattei
- University of Texas MD Anderson Cancer Center, Department of Cardiology, Division of Internal Medicine, Houston, United States of America
| | - J C Plana Gomez
- Texas Heart Institute, Medicine-Cardiology, Houston, United States of America
| | - G Oliveira
- University Hospitals Case Medical Center, Cardiology, Cleveland, United States of America
| | - M Fradley
- University of South Florida, Cardiology, Tampa, United States of America
| | - D Addison
- The Ohio State University, Internal Medicine, Division of Cardiovascular Medicine, Columbus, United States of America
| |
Collapse
|
37
|
Polk A, Buck B, Robertson M, Cook J, Felton C. Ankle Fracture Complications in the Elderly. Foot & Ankle Orthopaedics 2018. [DOI: 10.1177/2473011418s00385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Category: Trauma Introduction/Purpose: In the geriatric patient population, pre-existing medical conditions and poor bone quality often make operative fixation of unstable ankle fractures and fracture-dislocations more challenging. The objective of this study was to characterize the complications that occurred following operative fixation of these injuries at our institution and to determine whether complication rates were higher in our geriatric patient population (65 years and older) as compared to our younger patient population. We hypothesized that complication rates in the geriatric population would be significantly higher relative to complication rates in the younger population. We also hypothesized that in elderly patients, the soft tissue envelope would be less forgiving and require significantly more time for swelling to decrease to a level considered appropriate for definitive surgical fixation to occur. Methods: With IRB approval, a review of medical records for patients diagnosed with ankle fractures or fracture-dislocations and operated on between January of 2015 and December of 2016 was performed. Major complications were defined as any adverse outcomes requiring further surgical intervention such as irrigation and debridement for infection or exposed hardware, nonunion, major hardware failure, or amputation. Minor complications included other adverse outcomes which did not require further surgical intervention such as wound dehiscence, loss of reduction, or delayed union. Data were compared for statistically significant (p<0.05) differences. Results: Medical record review produced 110 patients meeting criteria for inclusion with a mean follow-up of 179 days (range, 0 to 601 days). No significant (p>0.08) differences were noted in rates of major, minor, or total complications between geriatric and younger patients treated at our institution (Fig. 1). An analysis of patient characteristics, demonstrated a significantly (p=0.035) higher proportion of trimalleolar ankle fractures within the geriatric population, but the proportions of other injury types were not significantly (p>0.198) different between age groups. Prevalence of tobacco use, alcohol use, illicit drug use, or diabetes mellitus was not found to be significantly different (p>0.058) between age groups. No significant (p=0.12) difference was found in time from injury to definitive surgical treatment between age groups. Conclusion: Complication rates following operative treatment of ankle fractures and fracture-dislocations were not significantly higher in our geriatric patient population, although the incidence of minor complications in the geriatric population was markedly increased relative to the younger population. A lack of significant difference in time from injury to definitive surgical treatment between age groups suggests that geriatric patients may not require a prolonged time for soft tissue swelling to decrease prior to surgery. Further study with a larger sample size is needed to determine if these findings are clinically significant.
Collapse
|
38
|
Wannamaker R, Guinand T, Menon BK, Demchuk A, Goyal M, Frei D, Bharatha A, Jovin TG, Shankar J, Krings T, Baxter B, Holmstedt C, Swartz R, Dowlatshahi D, Chan R, Tampieri D, Choe H, Burns P, Gentile N, Rempel J, Shuaib A, Buck B, Bivard A, Hill M, Butcher K. Computed Tomographic Perfusion Predicts Poor Outcomes in a Randomized Trial of Endovascular Therapy. Stroke 2018; 49:1426-1433. [DOI: 10.1161/strokeaha.117.019806] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/02/2018] [Accepted: 04/03/2018] [Indexed: 12/30/2022]
Abstract
Background and Purpose—
In the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times), patients with large vessel occlusions and small infarct cores identified with computed tomography (CT)/CT angiography were randomized to endovascular therapy or standard of care. CT perfusion (CTP) was obtained in some cases but was not used to select patients. We tested the hypothesis that patients with penumbral CTP patterns have higher rates of good clinical outcome.
Methods—
All CTP data acquired in ESCAPE patients were analyzed centrally using a semiautomated perfusion threshold-based approach. A penumbral pattern was defined as an infarct core <70 mL, penumbral volume >15 mL, and a total hypoperfused volume:core volume ratio of >1.8. The primary outcome was good functional outcome at 90 days (modified Rankin Scale score, 0–2).
Results—
CTP was acquired in 138 of 316 ESCAPE patients. Penumbral patterns were present in 116 of 128 (90.6%) of patients with interpretable CTP data. The rate of good functional outcome in penumbral pattern patients (53 of 114; 46%) was higher than that in nonpenumbral patients (2 of 12; 17%;
P
=0.041). In penumbral patients, endovascular therapy increased the likelihood of a good clinical outcome (34 of 58; 57%) compared with those in the control group (19 of 58; 33%; odds ratio, 2.68; 95% confidence interval, 1.25–5.76;
P
=0.011). Only 3 of 12 nonpenumbral patients were randomized to the endovascular group, preventing an analysis of treatment effect.
Conclusions—
The majority of patients with CTP imaging in the ESCAPE trial had penumbral patterns, which were associated with better outcomes overall. Patients with penumbra treated with endovascular therapy had the greatest odds of good functional outcome. Nonpenumbral patients were much less likely to achieve good outcomes.
Collapse
Affiliation(s)
| | - Taurian Guinand
- From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.)
| | - Bijoy K. Menon
- Division of Neurology, University of Calgary, Alberta, Canada (B.K.M., A.D., M.G., M.H.)
| | - Andrew Demchuk
- Division of Neurology, University of Calgary, Alberta, Canada (B.K.M., A.D., M.G., M.H.)
| | - Mayank Goyal
- Division of Neurology, University of Calgary, Alberta, Canada (B.K.M., A.D., M.G., M.H.)
| | - Donald Frei
- Department of Medical Imaging, Swedish Medical Center, Denver, CO (D.F.)
| | - Aditya Bharatha
- Department of Medical Imaging, St. Michael’s Hospital (A. Bharatha)
| | | | - Jai Shankar
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada (J.S.)
| | | | - Blaise Baxter
- Department of Radiology, University of Tennessee, Chattanooga (B. Baxter)
| | - Christine Holmstedt
- Division of Neurology, Medical University of South Carolina, Charleston (C.H.)
| | - Richard Swartz
- Division of Neurology (R.S.), University of Toronto, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada (D.D.)
| | - Richard Chan
- Division of Neurology, University of Western Ontario, London, Canada (R.C.)
| | - Donatella Tampieri
- Department of Radiology, McGill University Health Center, Montreal, Quebec, Canada (D.T.)
| | - Hana Choe
- Neurovascular Associates, Abington Jefferson Health, Philadelphia, PA (H.C.)
| | - Paul Burns
- Division of Neurology, Royal Victoria Hospital, Belfast, United Kingdom (P.B.)
| | - Nina Gentile
- Division of Neurology, Temple University, Philadelphia, PA (N.G.)
| | - Jeremy Rempel
- Department of Diagnostic Imaging (J.R.), University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.)
| | - Brian Buck
- From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.)
| | - Andrew Bivard
- Hunter Medical Research Institute, University of Newcastle, New South Wales, Australia (A. Bivard)
| | - Michael Hill
- Division of Neurology, University of Calgary, Alberta, Canada (B.K.M., A.D., M.G., M.H.)
| | - Kenneth Butcher
- From the Division of Neurology (R.W., T.G., A.S., B. Buck, K.B.)
| |
Collapse
|
39
|
Shuaib A, Amlani S, Kalashyan H, Morrison L, Khan K, Jickling G, Buck B, Butcher K, Saqqur M, Jeerakathil T. Mobile stroke unit triage of patients with a suspected stroke: a novel solution to reducing suspected stroke admissions in busy emergency departments. ACTA ACUST UNITED AC 2018. [DOI: 10.1136/bmjinnov-2017-000240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundEvaluation of patients with a suspected stroke is one of the most common neurological emergencies requiring rapid, comprehensive assessment by the stroke service to determine patient eligibility for timely reperfusion therapies. Prehospital evaluation may help to improve patient selection and reduce avoidable admissions to overcapacity emergency departments.Methods and resultsWe report on our early experience of prehospital triage of patients with a suspected stroke using a mobile stroke unit (MSU) equipped with CT scanner in rural Alberta. During the initial 4 months of operation, 28 patients were evaluated by the team in the MSU. Eight patients were within the time window of thrombolysis and were treated with intravenous tissue plasminogen activator in the MSU. No patients suffered haemorrhage or any other complications. Fourteen patients with multiple aetiologies (stroke mimics 6, transient ischaemic attacks 2, subacute stroke outside thrombolysis window 2, intracranial haemorrhage 3 and cerebral contusion 1) were assessed in the field and transferred to the tertiary hospital. Six patients after assessment and imaging were repatriated back to the local hospital as they were deemed stroke mimics or were outside of the reperfusion window.ConclusionsThe MSU offers a novel approach to performing timely evaluation and treatment of patients with a suspected stroke in rural settings and may help reduce admissions to overcapacity tertiary care facilities.
Collapse
|
40
|
Kate M, Wannamaker R, Kamble H, Riaz P, Gioia LC, Buck B, Jeerakathil T, Smyth P, Shuaib A, Emery D, Butcher K. Penumbral Imaging-Based Thrombolysis with Tenecteplase Is Feasible up to 24 Hours after Symptom Onset. J Stroke 2018; 20:122-130. [PMID: 29402060 PMCID: PMC5836582 DOI: 10.5853/jos.2017.00178] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Thrombolysis >4.5 hours after ischemic stroke onset is unproven. We assessed the feasibility of tenecteplase (TNK) treatment in patients with evidence of an ischemic penumbra 4.5 to 24 hours after onset. METHODS Acute ischemic stroke patients underwent perfusion computed tomography (CT)/magnetic resonance imaging. Patients with cerebral blood volume (CBV) or diffusion weighted imaging Alberta Stroke Program Early CT Scores (ASPECTS) >6 and mismatch score >2 (defined as >2 ASPECTS regions with delay on mean transit time maps and normal CBV) were eligible for treatment with TNK (0.25 mg/kg). Patients with mismatch patterns enrolled in non-endovascular/non-thrombolysis trials and those without mismatch patterns served as comparators. RESULTS The median (interquartile range) baseline National Institutes of Health Stroke Scale (NIHSS) in TNK treated patients (n=16) was 12 (range, 8 to 15). In the untreated mismatch (n=18) and nonmismatch (n=23) groups, the baseline NIHSS was 12 (range, 7 to 12) and 16 (range, 8 to 20; P=0.09) respectively. There was one symptomatic hemorrhage each in the TNK group (parenchymal hematoma [PH] 2) and non-mismatch group (PH 2). Penumbral salvage volumes were higher in TNK treated patients (48.3 mL [range, 24.9 to 80.4]) than the non-mismatch (-90.8 mL [range, -197 to -20]; P<0.0001) patients. CONCLUSIONS This prospective, non-randomized study supports the feasibility of TNK therapy in patients with evidence of ischemic penumbra 4 to 24 hours after onset.
Collapse
Affiliation(s)
- Mahesh Kate
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Robert Wannamaker
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Harsha Kamble
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Parnian Riaz
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Laura C Gioia
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Penelope Smyth
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Derek Emery
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Kenneth Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
41
|
Klahr AC, Dowlatshahi D, Buck B, Gioia L, Kalashyan H, Wilman A, Jeerakathil T, Emery D, Butcher K. Abstract WP339: Arterial Spin Labelling Cerebral Perfusion Measurements Demonstrate Normal Blood Flow in Subacute Intracerebral Hemorrhage Patients. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Perihematomal hypoperfusion in acute intracerebral hemorrhage (ICH) has been demonstrated using CT perfusion. Although blood pressure (BP) reduction does not appear to impact perihematomal Cerebral Blood Flow (CBF), measurements using contrast are limited to a single time point. It has also been shown that up to 41% of ICH patients develop subacute diffusion-weighted imaging (DWI) lesions on MRI. Arterial Spin Labelling (ASL) is an magnetic resonance imaging (MRI) technique that allows measurement of CBF without a contrast agent, making it suitable for serial measurements. We assessed CBF in ICH patients using ASL and tested the hypothesis that perihematoma perfusion is related to BP.
Methods:
Patients with CT scan confirmed ICH were prospectively recruited within 6 hours of symptom onset. Acute systolic BP (SBP) targets were randomly assigned as part of an ongoing trial. The SBP target remained blinded for this analysis. Patients were assessed with ASL at 48 hours post ICH. The perihematoma region was defined using co-registered susceptibility weighted images to delineate the hematoma border. Relative CBF (rCBF) was calculated as a ratio of the ipsilateral to contralateral ASL measurements.
Results:
Perfusion was measured in 6 ICH patients, none of whom had DWI lesions, 55.38 (43.72, 59.75) hours after onset. Median 48 hour hematoma volume was 23.40 (18.10, 99.90) ml. Mean±SD SBP at 48 hours was 140.20 ± 10.64 mmHg. Mean perihematomal rCBF was 0.95±0.37. Mean hemispheric rCBF was 0.95 ± 0.17. Perihematomal and hemispheric CBF was not lower in the side of the hematoma (
p
>0.583). Hematoma size was unrelated to rCBF (perihematomal R=0.039, 95% CI [-0.880, 0.959],
p
=0.682; hemispheric R=0.00, 95% CI [-0.005, 0.006],
p
=0.932). Systolic BP at the time of the scan, difference between baseline SBP and SBP at the time of the scan, and time spent with SBP <140 mmHg were all not associated with perihematomal or hemispheric rCBF (
p
>0.170).
Conclusion:
It is feasible to measure perihematoma and hemispheric perfusion in ICH patients using ASL, which may be useful for serial CBF assessment, particularly in patients with MRI evidence of ischemia.
Collapse
|
42
|
Klahr AC, Dowlatshahi D, Buck B, Gioia L, Kalashyan H, Wilman A, Jeerakathil T, Emery D, Butcher K. Abstract WMP104: Sub-Acute Diffusion-Weighted MRI Lesions in Acute Intracerebral Hemorrhage Patients are Unrelated to Blood Pressure. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wmp104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Diffusion-Weighted magnetic resonance imaging (DWI) studies have demonstrated sub-acute ischemic lesions in up to 41% of patients with intracerebral hemorrhage (ICH). Retrospective studies indicated an association with acute blood pressure (BP) reduction. We conducted a prospective study of DWI lesion incidence in ICH patients.
Methods:
Patients with computed tomography (CT) scan confirmed ICH were prospectively recruited within 6 hours of symptom onset. Acute systolic BP (SBP) targets were randomly assigned as part of an ongoing trial. The SBP target remained blinded for this analysis. Patients were assessed with serial DWI at 48 hours.
Results:
Eighty-three patients (48.2% male, mean±SD age 71.9±13.4) were enrolled. MRI was obtained in 42 patients. (11 patients were medically unstable, 11 refused consent, 19 died or were treated palliatively prior to the first MRI). Median (IQR) acute hematoma volume of the patients undergoing magnetic resonance imaging was 14.11 (4.40, 38.06) ml. Median baseline NIHSS score was 12.50 (9, 20). Median (IQR) 48 hour hematoma volume was 23.30 (9.10, 65.30) ml. DWI lesions were present in 13 (31%) of patients at 48 hours (median time to scan 54.22 (39.83, 65.5) hours). Mean SBP at 48 hours in patients with lesions (154.55±27.02 mmHg) was similar to those without (149.04±27.02;
p
= 0.514). Systolic BP at the time of the MRI was not a predictor of ischemic lesion development at 48 hours (OR=1.015, [0.972, 1.059],
p
=0.507), nor was the change in BP between baseline and the scan (OR=0.994, [0.962, 1.027],
p
=0.716). The only predictor of 48 hour DWI incidence was hematoma volume at 48 hours (OR= 1.025, 95% CI [1.001, 1.050],
p
=0.044).
Discussion:
When enrolled prospectively within 6 hours of onset, DWI was obtained in approximately half of all ICH patients. This selection bias may be relevant to the results of both retrospective and prospective DWI studies. This study demonstrated no evidence of a relationship between actual BP achieved and DWI incidence after ICH.
Collapse
|
43
|
Campbell BCV, van Zwam WH, Goyal M, Menon BK, Dippel DWJ, Demchuk AM, Bracard S, White P, Dávalos A, Majoie CBLM, van der Lugt A, Ford GA, de la Ossa NP, Kelly M, Bourcier R, Donnan GA, Roos YBWEM, Bang OY, Nogueira RG, Devlin TG, van den Berg LA, Clarençon F, Burns P, Carpenter J, Berkhemer OA, Yavagal DR, Pereira VM, Ducrocq X, Dixit A, Quesada H, Epstein J, Davis SM, Jansen O, Rubiera M, Urra X, Micard E, Lingsma HF, Naggara O, Brown S, Guillemin F, Muir KW, van Oostenbrugge RJ, Saver JL, Jovin TG, Hill MD, Mitchell PJ, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle J, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach Z, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Wakhloo A, Moonis M, Henninger N, Goddeau R, Massari F, Minaeian A, Lozano JD, Ramzan M, Stout C, Patel A, Majoie CB, Tunguturi A, Onteddu S, Carandang R, Howk M, Ribó M, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Dippel DW, Meler P, Huerga E, Gelabert S, Coscojuela P, Tomasello A, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Brown MM, Rovira A, Molina CA, Millán M, Muñoz L, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, Liebig T, García Bermejo P, Remollo S, Castaño C, García-Sort R, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Stijnen T, Dávalos A, Chamorro A, Urra X, Obach V, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Andersson T, Ariño H, Aceituno A, Rudilosso S, Renu A, Macho JM, San Roman L, Blasco J, López A, Macías N, Cardona P, Mattle H, Quesada H, Rubio F, Cano L, Lara B, de Miquel MA, Aja L, Serena J, Cobo E, Albers GW, Lees KR, Wahlgren N, Arenillas J, Roberts R, Minhas P, Al-Ajlan F, Salluzzi M, Zimmel L, Patel S, Eesa M, Martí-Fàbregas J, Jankowitz B, van der Heijden E, Serena J, Salvat-Plana M, López-Cancio E, Bracard S, Ducrocq X, Anxionnat R, Baillot PA, Barbier C, Derelle AL, Lacour JC, Ghannouti N, Richard S, Samson Y, Sourour N, Baronnet-Chauvet F, Clarencon F, Crozier S, Deltour S, Di Maria F, Le Bouc R, Leger A, Fleitour N, Mutlu G, Rosso C, Szatmary Z, Yger M, Zavanone C, Bakchine S, Pierot L, Caucheteux N, Estrade L, Kadziolka K, Hooijenga I, Leautaud A, Renkes C, Serre I, Desal H, Guillon B, Boutoleau-Bretonniere C, Daumas-Duport B, De Gaalon S, Derkinderen P, Evain S, Puppels C, Herisson F, Laplaud DA, Lebouvier T, Lintia-Gaultier A, Pouclet-Courtemanche H, Rouaud T, Rouaud Jaffrenou V, Schunck A, Sevin-Allouet M, Toulgoat F, Pellikaan W, Wiertlewski S, Gauvrit JY, Ronziere T, Cahagne V, Ferre JC, Pinel JF, Raoult H, Mas JL, Meder JF, Al Najjar-Carpentier AA, Geerling A, Birchenall J, Bodiguel E, Calvet D, Domigo V, Godon-Hardy S, Guiraud V, Lamy C, Majhadi L, Morin L, Naggara O, Lindl-Velema A, Trystram D, Turc G, Berge J, Sibon I, Menegon P, Barreau X, Rouanet F, Debruxelles S, Kazadi A, Renou P, van Vemde G, Fleury O, Pasco-Papon A, Dubas F, Caroff J, Godard Ducceschi S, Hamon MA, Lecluse A, Marc G, Giroud M, Ricolfi F, de Ridder A, Bejot Y, Chavent A, Gentil A, Kazemi A, Osseby GV, Voguet C, Mahagne MH, Sedat J, Chau Y, Suissa L, Greebe P, Lachaud S, Houdart E, Stapf C, Buffon Porcher F, Chabriat H, Guedin P, Herve D, Jouvent E, Mawet J, Saint-Maurice JP, de Bont-Stikkelbroeck J, Schneble HM, Turjman F, Nighoghossian N, Berhoune NN, Bouhour F, Cho TH, Derex L, Felix S, Gervais-Bernard H, Gory B, de Meris J, Manera L, Mechtouff L, Ritzenthaler T, Riva R, Salaris Silvio F, Tilikete C, Blanc R, Obadia M, Bartolini MB, Gueguen A, Janssen K, Piotin M, Pistocchi S, Redjem H, Drouineau J, Neau JP, Godeneche G, Lamy M, Marsac E, Velasco S, Clavelou P, Struijk W, Chabert E, Bourgois N, Cornut-Chauvinc C, Ferrier A, Gabrillargues J, Jean B, Marques AR, Vitello N, Detante O, Barbieux M, Licher S, Boubagra K, Favre Wiki I, Garambois K, Tahon F, Ashok V, Voguet C, Coskun O, Guedin P, Rodesch G, Lapergue B, Boodt N, Bourdain F, Evrard S, Graveleau P, Decroix JP, Wang A, Sellal F, Ahle G, Carelli G, Dugay MH, Gaultier C, Ros A, Lebedinsky AP, Lita L, Musacchio RM, Renglewicz-Destuynder C, Tournade A, Vuillemet F, Montoro FM, Mounayer C, Faugeras F, Gimenez L, Venema E, Labach C, Lautrette G, Denier C, Saliou G, Chassin O, Dussaule C, Melki E, Ozanne A, Puccinelli F, Sachet M, Slokkers I, Sarov M, Bonneville JF, Moulin T, Biondi A, De Bustos Medeiros E, Vuillier F, Courtheoux P, Viader F, Apoil-Brissard M, Bataille M, Ganpat RJ, Bonnet AL, Cogez J, Kazemi A, Touze E, Leclerc X, Leys D, Aggour M, Aguettaz P, Bodenant M, Cordonnier C, Mulder M, Deplanque D, Girot M, Henon H, Kalsoum E, Lucas C, Pruvo JP, Zuniga P, Bonafé A, Arquizan C, Costalat V, Saiedie N, Machi P, Mourand I, Riquelme C, Bounolleau P, Arteaga C, Faivre A, Bintner M, Tournebize P, Charlin C, Darcel F, Heshmatollah A, Gauthier-Lasalarie P, Jeremenko M, Mouton S, Zerlauth JB, Lamy C, Hervé D, Hassan H, Gaston A, Barral FG, Garnier P, Schipperen S, Beaujeux R, Wolff V, Herbreteau D, Debiais S, Murray A, Ford G, Muir KW, White P, Brown MM, Clifton A, Vinken S, Freeman J, Ford I, Markus H, Wardlaw J, Lees KR, Molyneux A, Robinson T, Lewis S, Norrie J, Robertson F, van Boxtel T, Perry R, Dixit A, Cloud G, Clifton A, Madigan J, Roffe C, Nayak S, Lobotesis K, Smith C, Herwadkar A, Koets J, Kandasamy N, Goddard T, Bamford J, Subramanian G, Lenthall R, Littleton E, Lamin S, Storey K, Ghatala R, Banaras A, Boers M, Aeron-Thomas J, Hazel B, Maguire H, Veraque E, Harrison L, Keshvara R, Cunningham J, Santos E, Borst J, Jansen I, Kappelhof M, Lucas M, Geuskens R, Barros RS, Dobbe R, Csizmadia M, Hill MD, Goyal M, Demchuk AM, Menon BK, Eesa M, Ryckborst KJ, Wright MR, Kamal NR, Andersen L, Randhawa PA, Stewart T, Patil S, Minhas P, Almekhlafi M, Mishra S, Clement F, Sajobi T, Shuaib A, Montanera WJ, Roy D, Silver FL, Jovin TG, Frei DF, Sapkota B, Rempel JL, Thornton J, Williams D, Tampieri D, Poppe AY, Dowlatshahi D, Wong JH, Mitha AP, Subramaniam S, Hull G, Lowerison MW, Sajobi T, Salluzzi M, Wright MR, Maxwell M, Lacusta S, Drupals E, Armitage K, Barber PA, Smith EE, Morrish WF, Coutts SB, Derdeyn C, Demaerschalk B, Yavagal D, Martin R, Brant R, Yu Y, Willinsky RA, Montanera WJ, Weill A, Kenney C, Aram H, Stewart T, Stys PK, Watson TW, Klein G, Pearson D, Couillard P, Trivedi A, Singh D, Klourfeld E, Imoukhuede O, Nikneshan D, Blayney S, Reddy R, Choi P, Horton M, Musuka T, Dubuc V, Field TS, Desai J, Adatia S, Alseraya A, Nambiar V, van Dijk R, Wong JH, Mitha AP, Morrish WF, Eesa M, Newcommon NJ, Shuaib A, Schwindt B, Butcher KS, Jeerakathil T, Buck B, Khan K, Naik SS, Emery DJ, Owen RJ, Kotylak TB, Ashforth RA, Yeo TA, McNally D, Siddiqui M, Saqqur M, Hussain D, Kalashyan H, Manosalva A, Kate M, Gioia L, Hasan S, Mohammad A, Muratoglu M, Williams D, Thornton J, Cullen A, Brennan P, O'Hare A, Looby S, Hyland D, Duff S, McCusker M, Hallinan B, Lee S, McCormack J, Moore A, O'Connor M, Donegan C, Brewer L, Martin A, Murphy S, O'Rourke K, Smyth S, Kelly P, Lynch T, Daly T, O'Brien P, O'Driscoll A, Martin M, Daly T, Collins R, Coughlan T, McCabe D, Murphy S, O'Neill D, Mulroy M, Lynch O, Walsh T, O'Donnell M, Galvin T, Harbison J, McElwaine P, Mulpeter K, McLoughlin C, Reardon M, Harkin E, Dolan E, Watts M, Cunningham N, Fallon C, Gallagher S, Cotter P, Crowe M, Doyle R, Noone I, Lapierre M, Coté VA, Lanthier S, Odier C, Durocher A, Raymond J, Weill A, Daneault N, Deschaintre Y, Jankowitz B, Baxendell L, Massaro L, Jackson-Graves C, Decesare S, Porter P, Armbruster K, Adams A, Billigan J, Oakley J, Ducruet A, Jadhav A, Giurgiutiu DV, Aghaebrahim A, Reddy V, Hammer M, Starr M, Totoraitis V, Wechsler L, Streib S, Rangaraju S, Campbell D, Rocha M, Gulati D, Silver FL, Krings T, Kalman L, Cayley A, Williams J, Stewart T, Wiegner R, Casaubon LK, Jaigobin C, del Campo JM, Elamin E, Schaafsma JD, Willinsky RA, Agid R, Farb R, ter Brugge K, Sapkoda BL, Baxter BW, Barton K, Knox A, Porter A, Sirelkhatim A, Devlin T, Dellinger C, Pitiyanuvath N, Patterson J, Nichols J, Quarfordt S, Calvert J, Hawk H, Fanale C, Frei DF, Bitner A, Novak A, Huddle D, Bellon R, Loy D, Wagner J, Chang I, Lampe E, Spencer B, Pratt R, Bartt R, Shine S, Dooley G, Nguyen T, Whaley M, McCarthy K, Teitelbaum J, Tampieri D, Poon W, Campbell N, Cortes M, Dowlatshahi D, Lum C, Shamloul R, Robert S, Stotts G, Shamy M, Steffenhagen N, Blacquiere D, Hogan M, AlHazzaa M, Basir G, Lesiuk H, Iancu D, Santos M, Choe H, Weisman DC, Jonczak K, Blue-Schaller A, Shah Q, MacKenzie L, Klein B, Kulandaivel K, Kozak O, Gzesh DJ, Harris LJ, Khoury JS, Mandzia J, Pelz D, Crann S, Fleming L, Hesser K, Beauchamp B, Amato-Marzialli B, Boulton M, Lopez- Ojeda P, Sharma M, Lownie S, Chan R, Swartz R, Howard P, Golob D, Gladstone D, Boyle K, Boulos M, Hopyan J, Yang V, Da Costa L, Holmstedt CA, Turk AS, Navarro R, Jauch E, Ozark S, Turner R, Phillips S, Shankar J, Jarrett J, Gubitz G, Maloney W, Vandorpe R, Schmidt M, Heidenreich J, Hunter G, Kelly M, Whelan R, Peeling L, Burns PA, Hunter A, Wiggam I, Kerr E, Watt M, Fulton A, Gordon P, Rennie I, Flynn P, Smyth G, O'Leary S, Gentile N, Linares G, McNelis P, Erkmen K, Katz P, Azizi A, Weaver M, Jungreis C, Faro S, Shah P, Reimer H, Kalugdan V, Saposnik G, Bharatha A, Li Y, Kostyrko P, Santos M, Marotta T, Montanera W, Sarma D, Selchen D, Spears J, Heo JH, Jeong K, Kim DJ, Kim BM, Kim YD, Song D, Lee KJ, Yoo J, Bang OY, Rho S, Lee J, Jeon P, Kim KH, Cha J, Kim SJ, Ryoo S, Lee MJ, Sohn SI, Kim CH, Ryu HG, Hong JH, Chang HW, Lee CY, Rha J, Davis SM, Donnan GA, Campbell BCV, Mitchell PJ, Churilov L, Yan B, Dowling R, Yassi N, Oxley TJ, Wu TY, Silver G, McDonald A, McCoy R, Kleinig TJ, Scroop R, Dewey HM, Simpson M, Brooks M, Coulton B, Krause M, Harrington TJ, Steinfort B, Faulder K, Priglinger M, Day S, Phan T, Chong W, Holt M, Chandra RV, Ma H, Young D, Wong K, Wijeratne T, Tu H, Mackay E, Celestino S, Bladin CF, Loh PS, Gilligan A, Ross Z, Coote S, Frost T, Parsons MW, Miteff F, Levi CR, Ang T, Spratt N, Kaauwai L, Badve M, Rice H, de Villiers L, Barber PA, McGuinness B, Hope A, Moriarty M, Bennett P, Wong A, Coulthard A, Lee A, Jannes J, Field D, Sharma G, Salinas S, Cowley E, Snow B, Kolbe J, Stark R, King J, Macdonnell R, Attia J, D'Este C, Saver JL, Goyal M, Diener HC, Levy EI, Bonafé A, Mendes Pereira V, Jahan R, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, von Kummer R, Smith W, Turjman F, Hamilton S, Chiacchierini R, Amar A, Sanossian N, Loh Y, Devlin T, Baxter B, Hawk H, Sapkota B, Quarfordt S, Sirelkhatim A, Dellinger C, Barton K, Reddy VK, Ducruet A, Jadhav A, Horev A, Giurgiutiu DV, Totoraitis V, Hammer M, Jankowitz B, Wechsler L, Rocha M, Gulati D, Campbell D, Star M, Baxendell L, Oakley J, Siddiqui A, Hopkins LN, Snyder K, Sawyer R, Hall S, Costalat V, Riquelme C, Machi P, Omer E, Arquizan C, Mourand I, Charif M, Ayrignac X, Menjot de Champfleur N, Leboucq N, Gascou G, Moynier M, du Mesnil de Rochemont R, Singer O, Berkefeld J, Foerch C, Lorenz M, Pfeilschifer W, Hattingen E, Wagner M, You SJ, Lescher S, Braun H, Dehkharghani S, Belagaje SR, Anderson A, Lima A, Obideen M, Haussen D, Dharia R, Frankel M, Patel V, Owada K, Saad A, Amerson L, Horn C, Doppelheuer S, Schindler K, Lopes DK, Chen M, Moftakhar R, Anton C, Smreczak M, Carpenter JS, Boo S, Rai A, Roberts T, Tarabishy A, Gutmann L, Brooks C, Brick J, Domico J, Reimann G, Hinrichs K, Becker M, Heiss E, Selle C, Witteler A, Al-Boutros S, Danch MJ, Ranft A, Rohde S, Burg K, Weimar C, Zegarac V, Hartmann C, Schlamann M, Göricke S, Ringlestein A, Wanke I, Mönninghoff C, Dietzold M, Budzik R, Davis T, Eubank G, Hicks WJ, Pema P, Vora N, Mejilla J, Taylor M, Clark W, Rontal A, Fields J, Peterson B, Nesbit G, Lutsep H, Bozorgchami H, Priest R, Ologuntoye O, Barnwell S, Dogan A, Herrick K, Takahasi C, Beadell N, Brown B, Jamieson S, Hussain MS, Russman A, Hui F, Wisco D, Uchino K, Khawaja Z, Katzan I, Toth G, Cheng-Ching E, Bain M, Man S, Farrag A, George P, John S, Shankar L, Drofa A, Dahlgren R, Bauer A, Itreat A, Taqui A, Cerejo R, Richmond A, Ringleb P, Bendszus M, Möhlenbruch M, Reiff T, Amiri H, Purrucker J, Herweh C, Pham M, Menn O, Ludwig I, Acosta I, Villar C, Morgan W, Sombutmai C, Hellinger F, Allen E, Bellew M, Gandhi R, Bonwit E, Aly J, Ecker RD, Seder D, Morris J, Skaletsky M, Belden J, Baker C, Connolly LS, Papanagiotou P, Roth C, Kastrup A, Politi M, Brunner F, Alexandrou M, Merdivan H, Ramsey C, Given II C, Renfrow S, Deshmukh V, Sasadeusz K, Vincent F, Thiesing JT, Putnam J, Bhatt A, Kansara A, Caceves D, Lowenkopf T, Yanase L, Zurasky J, Dancer S, Freeman B, Scheibe-Mirek T, Robison J, Rontal A, Roll J, Clark D, Rodriguez M, Fitzsimmons BFM, Zaidat O, Lynch JR, Lazzaro M, Larson T, Padmore L, Das E, Farrow-Schmidt A, Hassan A, Tekle W, Cate C, Jansen O, Cnyrim C, Wodarg F, Wiese C, Binder A, Riedel C, Rohr A, Lang N, Laufs H, Krieter S, Remonda L, Diepers M, Añon J, Nedeltchev K, Kahles T, Biethahn S, Lindner M, Chang V, Gächter C, Esperon C, Guglielmetti M, Arenillas Lara JF, Martínez Galdámez M, Calleja Sanz AI, Cortijo Garcia E, Garcia Bermejo P, Perez S, Mulero Carrillo P, Crespo Vallejo E, Ruiz Piñero M, Lopez Mesonero L, Reyes Muñoz FJ, Brekenfeld C, Buhk JH, Krützelmann A, Thomalla G, Cheng B, Beck C, Hoppe J, Goebell E, Holst B, Grzyska U, Wortmann G, Starkman S, Duckwiler G, Jahan R, Rao N, Sheth S, Ng K, Noorian A, Szeder V, Nour M, McManus M, Huang J, Tarpley J, Tateshima S, Gonzalez N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol 2018; 17:47-53. [DOI: 10.1016/s1474-4422(17)30407-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/05/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
|
44
|
van Gaal SC, Kamal N, Betzner MJ, Vilneff RL, Mann B, Lang ES, Demchuk A, Buck B, Jeerakathil T, Hill MD. Approaches to the field recognition of potential thrombectomy candidates. Int J Stroke 2017; 12:698-707. [DOI: 10.1177/1747493017724585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Systems of care for acute ischemic stroke are being challenged to implement processes that ensure rapid access to endovascular thrombectomy. Optimizing existing regionalized stroke thrombolysis programs for endovascular thrombectomy will require accurate field recognition of treatment candidates. We begin with a review of the development of early clinical tests for ischemic stroke, illustrating challenges relevant to future field tests for large vessel occlusion. Second, we discuss aspects of diagnosis, eligibility, feasibility, and system organization that are potentially relevant to the development and implementation of field tests and diversion criteria. These considerations may influence the choice and parametrization of field tests in individual jurisdictions. Third, we review the literature evaluating eight clinical tests for the field identification of probable large vessel occlusion. All candidate tests include evaluations for focal weakness, and six evaluate for cortical signs such as aphasia or gaze deviation. Most appear roughly comparable to the NIH Stroke Scale, but direct comparison between studies is inappropriate because of major methodological differences. Finally, we discuss our jurisdiction’s approach to the field recognition of thrombectomy candidates. We contextualize diagnostic, eligibility, and system considerations within distinct metro and rural environments and propose a screen-and-consult model for the rural setting.
Collapse
Affiliation(s)
- Stephen C van Gaal
- Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Noreen Kamal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Electrical and Computer Engineering, University of Calgary, Calgary, Canada
| | - Michael J Betzner
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
- Shock Trauma Air Rescue Service, Calgary, Canada
| | - Renee L Vilneff
- Emergency Medical Services, Alberta Health Services, Calgary, Canada
| | - Balraj Mann
- Cardiovascular and Stroke Strategic Clinical Network, Alberta Health Services, Edmonton, Canada
| | - Eddy S Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Andrew Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Brian Buck
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| |
Collapse
|
45
|
Buck B, Guha A, Gao X, Dunleavy M, Liu E, Haddad D, Efebera Y, Baliga R. P4690Trends in hospitalizations of patients with acute coronary syndrome and concurrent amyloidosis. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p4690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
46
|
Lanthier S, Saposnik G, Lebovic G, Pope K, Selchen D, Moore DF, Selchen D, Boulanger JM, Buck B, Butcher K, del Campo M, Gosselin S, Hachinski V, Hill MD, Mackey A, Mehdiratta M, Spence JD, Stotts G, Swartz R, West ML, Yegappan C. Prevalence of Fabry Disease and Outcomes in Young Canadian Patients With Cryptogenic Ischemic Cerebrovascular Events. Stroke 2017; 48:1766-1772. [DOI: 10.1161/strokeaha.116.016083] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/07/2017] [Accepted: 04/20/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Previous studies reported Fabry disease in 0% to 4% of young patients with cryptogenic ischemic stroke (IS). We sought to determine the prevalence of Fabry and outcomes among young Canadians with cryptogenic IS or transient ischemic attack (TIA).
Methods—
We prospectively enrolled individuals aged 18 to 55 with IS or speech or motor TIA, and no cause identified despite predetermined investigation.
α-galactosidase-A
gene was sequenced for Fabry diagnosis. National Institutes of Health Stroke Scale score was measured at presentation to quantify stroke severity. Modified Rankin Scale determined functional outcomes ≤7 days after presentation and 6 months later.
Results—
We enrolled 365 patients with IS and 32 with TIA.
α-galactosidase-A
sequencing identified a single carrier of a genetic variant of unknown significance (p.R118C) and no well-recognized pathogenic variants. Mean National Institutes of Health Stroke Scale score was 3.1. Proportion of patients with modified Rankin Scale of 0 to 2 was 70.7% at ≤7 days and 87.4% at 6 months. National Institutes of Health Stroke Scale score at presentation and diabetes mellitus predicted 6-month modified Rankin Scale. Thirteen patients experienced 5 recurrent IS and 9 TIA during follow-up. No patient died. Most patients (98.7%) returned home. Among previous workers, 43% had residual working limitations.
Conclusions—
In this Canadian cohort of patients with cryptogenic IS or TIA, the prevalence of Fabry was 0.3% if p.R118C variant is considered as pathogenic. This suggests that more cost-effective methods should be applied for diagnosis of Fabry rather than systematic genetic screening in this population. Overall, cryptogenic IS in young adults is associated with favorable outcomes.
Collapse
Affiliation(s)
- Sylvain Lanthier
- From the Division of Neurology, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Quebec, Canada (S.L.); Department of Neurosciences, Faculty of Medicine, University of Montreal, Quebec, Canada (S.L.); Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine (G.S., D.S.), Department of Health Policy, Management and Evaluation (G.S.), Applied Health Research Centre (G.L., K.P.), St. Michael’s Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and
| | - Gustavo Saposnik
- From the Division of Neurology, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Quebec, Canada (S.L.); Department of Neurosciences, Faculty of Medicine, University of Montreal, Quebec, Canada (S.L.); Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine (G.S., D.S.), Department of Health Policy, Management and Evaluation (G.S.), Applied Health Research Centre (G.L., K.P.), St. Michael’s Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and
| | - Gerald Lebovic
- From the Division of Neurology, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Quebec, Canada (S.L.); Department of Neurosciences, Faculty of Medicine, University of Montreal, Quebec, Canada (S.L.); Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine (G.S., D.S.), Department of Health Policy, Management and Evaluation (G.S.), Applied Health Research Centre (G.L., K.P.), St. Michael’s Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and
| | - Karen Pope
- From the Division of Neurology, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Quebec, Canada (S.L.); Department of Neurosciences, Faculty of Medicine, University of Montreal, Quebec, Canada (S.L.); Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine (G.S., D.S.), Department of Health Policy, Management and Evaluation (G.S.), Applied Health Research Centre (G.L., K.P.), St. Michael’s Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and
| | - Daniel Selchen
- From the Division of Neurology, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Quebec, Canada (S.L.); Department of Neurosciences, Faculty of Medicine, University of Montreal, Quebec, Canada (S.L.); Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine (G.S., D.S.), Department of Health Policy, Management and Evaluation (G.S.), Applied Health Research Centre (G.L., K.P.), St. Michael’s Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and
| | - David F. Moore
- From the Division of Neurology, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Quebec, Canada (S.L.); Department of Neurosciences, Faculty of Medicine, University of Montreal, Quebec, Canada (S.L.); Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine (G.S., D.S.), Department of Health Policy, Management and Evaluation (G.S.), Applied Health Research Centre (G.L., K.P.), St. Michael’s Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Gioia L, Klahr A, Kate M, Buck B, Dowlatshahi D, Jeerakathil T, Emery D, Butcher K. The intracerebral hemorrhage acutely decreasing arterial pressure trial II (ICH ADAPT II) protocol. BMC Neurol 2017; 17:100. [PMID: 28525977 PMCID: PMC5437568 DOI: 10.1186/s12883-017-0884-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/10/2017] [Indexed: 11/19/2022] Open
Abstract
Background Aggressively lowering blood pressure (BP) in acute intracerebral hemorrhage (ICH) may improve outcome. Although there is no evidence that BP reduction changes cerebral blood flow, retrospective magnetic resonance imaging (MRI) studies have demonstrated sub-acute ischemic lesions in ICH patients. The primary aim of this study is to assess ischemic lesion development in patients randomized to two different BP treatment strategies. We hypothesize aggressive BP reduction is not associated with ischemic injury after ICH. Methods The Intracerebral Hemorrhage Acutely Decreasing Blood Pressure Trial II (ICH ADAPT II) is a phase II multi-centre randomized open-label, blinded-endpoint trial. Acute ICH patients (N = 270) are randomized to a systolic blood pressure (SBP) target of <140 or <180 mmHg. Acute ICH patients within 6 h of onset and two SBP measurements ≥140 mmHg recorded >2 mins apart qualify. SBP is managed with a pre-defined treatment protocol. Patients undergo MRI at 48 h, Days 7 and 30, with clinical assessment at Day 30 and 90. The primary outcome is diffusion weighted imaging (DWI) lesion frequency at 48 h. Secondary outcomes include cumulative DWI lesion rate frequency within 30 days, absolute hematoma growth, prediction of DWI lesion incidence, 30-day mortality rates, day 90 functional outcome, and cognitive status. Discussion This trial will assess the impact of hypertensive therapies on physiological markers of ischemic injury. The findings of this study will provide evidence for the link, or lack thereof, between BP reduction and ischemic injury in ICH patients. Trial registration This study is registered with clinicaltrials.gov (NCT02281838, first received October 29, 2014). Electronic supplementary material The online version of this article (doi:10.1186/s12883-017-0884-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laura Gioia
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Ana Klahr
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Mahesh Kate
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Brian Buck
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | | | - Thomas Jeerakathil
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada
| | - Derek Emery
- Department of Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Kenneth Butcher
- Division of Neurology, University of Alberta, 7th Floor Clinical Sciences Building, 11350-83rd Avenue, Edmonton, AB, T6G 2B7, Canada.
| |
Collapse
|
48
|
Abstract
Traumatic bone defects of the distal femur and proximal tibia present treatment challenges for the orthopaedic traumatologist. In addition to bone loss, significant soft tissue compromise and cartilage defects leave the patient and surgeon with few reconstructive options for proper long-term joint function. These injuries are often complicated by delayed healing, nonunion, malunion, infection, and poor subjective patient outcomes. There are a variety of clinical problems associated with the treatment of periarticular fractures about the knee. This article will describe the surgical options for these difficult problems.
Collapse
Affiliation(s)
- Brian Buck
- Department of Orthopaedic Surgery, University of Missouri Health Care, Columbia, Missouri
| | - Yvonne M Murtha
- Department of Orthopaedic Surgery, University of Missouri Health Care, Columbia, Missouri
| |
Collapse
|
49
|
Sivakumar L, Riaz P, Kate M, Jeerakathil T, Beaulieu C, Buck B, Camicioli R, Butcher K. White matter hyperintensity volume predicts persistent cognitive impairment in transient ischemic attack and minor stroke. Int J Stroke 2016; 12:264-272. [PMID: 27784823 DOI: 10.1177/1747493016676612] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Temporary and permanent cognitive changes following transient ischemic attack/minor stroke have been described previously. It is unknown if persisting cognitive deficits in these patients are correlated with acute infarction identified using magnetic resonance imaging. Aims We tested the hypothesis that persistent cognitive impairment after transient ischemic attack/minor stroke can be predicted by the volume of diffusion-weighted imaging lesions. Methods Acute transient ischemic attack/minor stroke (NIH stroke scale score ≤ 3) patients were prospectively recruited within 72 h of onset. Patients underwent Montreal cognitive assessment and magnetic resonance imaging, including diffusion-weighted imaging and Fluid-Attenuated Inverse Recovery sequences, at baseline, days 7 and 30. Cognitive testing was repeated at day 90. Diffusion-weighted imaging lesion and Fluid-Attenuated Inverse Recovery chronic white matter hyperintensity volumes were measured planimetrically. Cognitive impairment was defined a priori as Montreal cognitive assessment score < 26. Results One hundred fifteen patients were imaged at a median (inter-quartile range) of 24.0 (16.6) h after onset. Acute ischemic lesions were present in 91 (79%) patients. Cognitive impairment rates were similar in patients with (47/91, 52%) and without diffusion-weighted imaging lesions (13/24, 54%; p = 0.83). Although linear regression indicated no relationship between acute diffusion-weighted imaging lesion volume and day 30 Montreal cognitive assessment scores (β = -0.163, [-2.243, 0.334], p = 0.144), white matter hyperintensity volumes at baseline were predictive of persistent cognitive deficits after 30 days (β = 2.24, [1.956, 45.369], p = 0.005). Conclusions In most transient ischemic attack/minor stroke patients who suffer acute cognitive impairment post event, deficits are temporary. Deficits after 30 days of onset are correlated with chronic white matter hyperintensity, suggesting subclinical cognitive impairment and/or impaired ability to compensate for the effects of acute ischemic infarcts.
Collapse
Affiliation(s)
- Leka Sivakumar
- 1 Division of Neurology, University of Alberta, Alberta, Canada
| | - Parnian Riaz
- 1 Division of Neurology, University of Alberta, Alberta, Canada
| | - Mahesh Kate
- 1 Division of Neurology, University of Alberta, Alberta, Canada
| | | | - Christian Beaulieu
- 2 Division of Biomedical Engineering, University of Alberta, Alberta, Canada
| | - Brian Buck
- 1 Division of Neurology, University of Alberta, Alberta, Canada
| | | | - Ken Butcher
- 1 Division of Neurology, University of Alberta, Alberta, Canada
| |
Collapse
|
50
|
Gioia LC, Kate M, Sivakumar L, Hussain D, Kalashyan H, Buck B, Bussiere M, Jeerakathil T, Shuaib A, Emery D, Butcher K. Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation. Stroke 2016; 47:1917-9. [DOI: 10.1161/strokeaha.116.013491] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 05/06/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Laura C. Gioia
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Mahesh Kate
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Leka Sivakumar
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Dulara Hussain
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Hayrapet Kalashyan
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Brian Buck
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Miguel Bussiere
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Thomas Jeerakathil
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Ashfaq Shuaib
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Derek Emery
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| | - Ken Butcher
- From the Division of Neurology, University of Montreal, Montreal, Canada (L.C.G.); and Division of Neurology (M.K., L.S., D.H., H.K., B.B., M.B., T.J., A.S., K.B.), and Department of Diagnostic Imaging (D.E.), University of Alberta, Alberta, Canada
| |
Collapse
|