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Deuschl C, Goertz L, Kabbasch C, Köhrmann M, Kleinschnitz C, Berlis A, Maurer CJ, Mühlen I, Kallmünzer B, Gawlitza M, Kaiser DPO, Klisch J, Lobsien D, Behme D, Thormann M, Flottmann F, Winkelmeier L, Gizewski ER, Mayer-Suess L, Holtmannspoetter M, Moenninghoff C, Schlunz-Hendann M, Grieb D, Arendt CT, Bohmann FO, Altenbernd J, Li Y, Sure U, Mühl-Benninghaus R, Rodt T, Kallenberg K, Durutya A, Elsharkawy M, Stracke CP, Schumann MG, Bock A, Nikoubashman O, Wiesmann M, Henkes H, Dolff S, Demircioglu A, Forsting M, Styczen H. Impact of Vaccination Status on Outcome of Patients With COVID-19 and Acute Ischemic Stroke Undergoing Mechanical Thrombectomy. J Am Heart Assoc 2024; 13:e031816. [PMID: 38639365 DOI: 10.1161/jaha.123.031816] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Data on impact of COVID-19 vaccination and outcomes of patients with COVID-19 and acute ischemic stroke undergoing mechanical thrombectomy are scarce. Addressing this subject, we report our multicenter experience. METHODS AND RESULTS This was a retrospective analysis of patients with COVID-19 and known vaccination status treated with mechanical thrombectomy for acute ischemic stroke at 20 tertiary care centers between January 2020 and January 2023. Baseline demographics, angiographic outcome, and clinical outcome evaluated by the modified Rankin Scale score at discharge were noted. A multivariate analysis was conducted to test whether these variables were associated with an unfavorable outcome, defined as modified Rankin Scale score >3. A total of 137 patients with acute ischemic stroke (48 vaccinated and 89 unvaccinated) with acute or subsided COVID-19 infection who underwent mechanical thrombectomy attributable to vessel occlusion were included in the study. Angiographic outcomes between vaccinated and unvaccinated patients were similar (modified Thrombolysis in Cerebral Infarction ≥2b: 85.4% in vaccinated patients versus 86.5% in unvaccinated patients; P=0.859). The rate of functional independence (modified Rankin Scale score, ≤2) was 23.3% in the vaccinated group and 20.9% in the unvaccinated group (P=0.763). The mortality rate was 30% in both groups. In the multivariable analysis, vaccination status was not a significant predictor for an unfavorable outcome (P=0.957). However, acute COVID-19 infection remained significant (odds ratio, 1.197 [95% CI, 1.007-1.417]; P=0.041). CONCLUSIONS Our study demonstrated no impact of COVID-19 vaccination on angiographic or clinical outcome of COVID-19-positive patients with acute ischemic stroke undergoing mechanical thrombectomy, whereas worsening attributable to COVID-19 was confirmed.
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Affiliation(s)
- Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
| | - Lukas Goertz
- Department of Diagnostic and Interventional Radiology University Hospital Cologne Cologne Germany
| | - Christoph Kabbasch
- Department of Diagnostic and Interventional Radiology University Hospital Cologne Cologne Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neurosciences and Behavioral Sciences University Hospital Essen Essen Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neurosciences and Behavioral Sciences University Hospital Essen Essen Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Neuroradiology University Hospital Augsburg Augsburg Germany
| | - Christoph Johannes Maurer
- Department of Diagnostic and Interventional Neuroradiology University Hospital Augsburg Augsburg Germany
| | - Iris Mühlen
- Department of Neuroradiology University of Erlangen-Nuremberg Erlangen Germany
| | - Bernd Kallmünzer
- Department of Neurology University of Erlangen-Nuremberg Erlangen Germany
| | - Matthias Gawlitza
- Faculty of Medicine, Institute and Policlinic of Neuroradiology, University Hospital Carl Gustav Carus Technische Universität Dresden Dresden Germany
- Department of Neuroradiology University Hospital Leipzig Leipzig Germany
| | - Daniel P O Kaiser
- Faculty of Medicine, Institute and Policlinic of Neuroradiology, University Hospital Carl Gustav Carus Technische Universität Dresden Dresden Germany
| | - Joachim Klisch
- Department of Diagnostic and Interventional Radiology and Neuroradiology Helios General Hospital Erfurt Erfurt Germany
| | - Donald Lobsien
- Department of Diagnostic and Interventional Radiology and Neuroradiology Helios General Hospital Erfurt Erfurt Germany
| | - Daniel Behme
- Department of Neuroradiology University Hospital Magdeburg Magdeburg Germany
| | | | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Elke Ruth Gizewski
- Department of Neuroradiology Medical University Innsbruck Innsbruck Austria
| | - Lukas Mayer-Suess
- Department of Neurology Medical University Innsbruck Innsbruck Austria
| | | | - Christoph Moenninghoff
- Department of Radiology, Neuroradiology and Nuclear Medicine Johannes Wesling University Hospital, Ruhr University Bochum Bochum Germany
| | - Martin Schlunz-Hendann
- Department of Radiology and Neuroradiology Klinikum Duisburg-Sana Kliniken Duisburg Germany
| | - Dominik Grieb
- Department of Radiology and Neuroradiology Klinikum Duisburg-Sana Kliniken Duisburg Germany
- Department of Diagnostic and Interventional Neuroradiology Medical School Hannover Hannover Germany
| | - Christophe T Arendt
- Institute of Neuroradiology, University Hospital Goethe University Frankfurt am Main Germany
| | - Ferdinand O Bohmann
- Institute of Neuroradiology, University Hospital Goethe University Frankfurt am Main Germany
| | - Jens Altenbernd
- Department of Radiology and Neuroradiology Gemeinschaftskrankenhaus Herdecke Herdecke Germany
| | - Yan Li
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery University Hospital of Essen Essen Germany
| | | | - Thomas Rodt
- Department of Radiology Klinikum Lueneburg Lueneburg Germany
| | - Kai Kallenberg
- Department of Neuroradiology Klinikum Fulda Fulda Germany
| | | | | | | | | | - Alexander Bock
- Department of Neuroradiology Vivantes Klinikum Neukoelln Berlin Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology University Hospital, Rheinisch-Westfälische Technische Hochschule Aachen University Aachen Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology University Hospital, Rheinisch-Westfälische Technische Hochschule Aachen University Aachen Germany
| | - Hans Henkes
- Clinic for Neuroradiology Klinikum Stuttgart Stuttgart Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, West German Centre of Infectious Diseases University Hospital Essen Essen Germany
| | - Aydin Demircioglu
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
| | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen Germany
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Winkelmeier L, Maros M, Flottmann F, Heitkamp C, Schön G, Thomalla G, Fiehler J, Hanning U. Endovascular Thrombectomy for Large Ischemic Strokes with ASPECTS 0-2: a Meta-analysis of Randomized Controlled Trials. Clin Neuroradiol 2024:10.1007/s00062-024-01414-2. [PMID: 38687364 DOI: 10.1007/s00062-024-01414-2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Randomized controlled trials (RCTs) demonstrated a treatment effect of endovascular thrombectomy in acute ischemic stroke with large infarct, commonly defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. However, data on endovascular thrombectomy in patients with very low ASPECTS of 0-2 remain scarce. METHODS We conducted a systematic review and meta-analysis of RCTs comparing endovascular thrombectomy versus medical treatment alone in acute ischemic anterior circulation stroke with very large infarct, defined as ASPECTS of 0-2. The primary outcome was the shift toward better functional outcomes on the 90-day modified Rankin Scale (mRS). Random effects meta-analysis was performed using the generic inverse variance method. RESULTS Literature research identified four RCTs which evaluated the treatment effect of endovascular thrombectomy for large infarcts and provided a subgroup analysis of the mRS shift in patients with ASPECTS of 0-2. The pooled analysis showed a significant shift toward better 90-day mRS scores in favor of endovascular thrombectomy (pooled odds ratio, 1.62, 95% confidence interval, 1.29-2.04, P < 0.001). CONCLUSION This meta-analysis suggests a treatment effect of endovascular thrombectomy in specific patients with very low ASPECTS of 0-2, challenging the use of ASPECTS for treatment selection in acute ischemic stroke due to large vessel occlusion. An individual patient meta-analysis of RCTs would strengthen evidence in the treatment of patients with ASPECTS of 0-2.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Máté Maros
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Biomedical Informatics, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Kniep H, Meyer L, Broocks G, Bechstein M, Austein F, McDonough RV, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellissen S. How much of the outcome improvement after successful recanalization is explained by follow-up infarct volume reduction? J Neurointerv Surg 2024; 16:459-465. [PMID: 37230748 DOI: 10.1136/jnis-2023-020296] [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: 03/08/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Follow-up infarct volume (FIV) is used as surrogate for treatment efficiency in mechanical thrombectomy (MT). However, previous works suggest that MT-related FIV reduction has only limited association with outcome comparing MT independently of recanalization success versus medical care. It remains unclear to what extent the relationship between successful recanalization versus persistent occlusion and functional outcome is explained by FIV reduction. OBJECTIVE To determine whether FIV mediates the relationship between successful recanalization and functional outcome. METHODS All patients from our institution enrolled in the German Stroke Registry (May 2015-December 2019) with anterior circulation stroke; availability of the relevant clinical data, and follow-up-CT were analyzed. The effect of FIV reduction on functional outcome (90-day modified Rankin Scale (mRS) score ≤2) after successful recanalization (Thrombolysis in Cerebral Infarction ≥2b) was quantified using mediation analysis. RESULTS 429 patients were included, of whom, 309 (72 %) had successful recanalization and 127 (39%) had good functional outcome. Good outcome was associated with age (OR=0.89, P<0.001), pre-stroke mRS score (OR=0.38, P<0.001), FIV (OR=0.98, P<0.001), hypertension (OR=2.08, P<0.05), and successful recanalization (OR=3.57, P<0.01). Using linear regression in the mediator pathway, FIV was associated with Alberta Stroke program Early CT Score (coefficient (Co)=-26.13, P<0.001), admission National Institutes of Health Stroke Scale score (Co=3.69, P<0.001), age (Co=-1.18, P<0.05), and successful recanalization (Co=-85.22, P<0.001). Successful recanalization increased the probability of good outcome by 23 percentage points (pp) (95% CI 16pp to 29pp). 56% (95% CI 38% to 78%) of the improvement in good outcome was explained by FIV reduction. CONCLUSION 56% (95% CI 38% to 78%) of outcome improvement after successful recanalization was explained by FIV reduction. Results corroborate pathophysiological assumptions and confirm the value of FIV as an imaging endpoint in clinical trials. 44% (95% CI 22% to 62%) of the improvement in outcome was not explained by FIV reduction and reflects the remaining mismatch between radiological and clinical outcome measures.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Austein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie V McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Winkelmeier L, Heitkamp C, Faizy TD, Broocks G, Kniep H, Meyer L, Bester M, Brekenfeld C, Schell M, Hanning U, Thomalla G, Fiehler J, Flottmann F. Prognostic value of recanalization attempts in endovascular therapy for M2 segment middle cerebral artery occlusions. Int J Stroke 2024; 19:422-430. [PMID: 37935652 PMCID: PMC10964385 DOI: 10.1177/17474930231214769] [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: 07/31/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND There is growing evidence suggesting efficacy of endovascular therapy for M2 occlusions of the middle cerebral artery. More than one recanalization attempt is often required to achieve successful reperfusion in M2 occlusions, associated with general concerns about the safety of multiple maneuvers in these medium vessel occlusions. AIM The aim of this study was to investigate the association between the number of recanalization attempts and functional outcomes in M2 occlusions in comparison with large vessel occlusions (LVO). METHODS Retrospective multicenter cohort study of patients who underwent endovascular therapy for primary M2 occlusions. Patients were enrolled in the German Stroke Registry at 1 of 25 comprehensive stroke centers between 2015 and 2021. The study cohort was subdivided into patients with unsuccessful reperfusion (mTICI 0-2a) and successful reperfusion (mTICI 2b-3) at first, second, third, fourth, or ⩾fifth recanalization attempt. Primary outcome was 90-day functional independence defined as modified Rankin Scale score of 0-2. Safety outcome was the occurrence of symptomatic intracranial hemorrhage. Internal carotid artery or M1 occlusions were defined as LVO and served as comparison group. RESULTS A total of 1078 patients with M2 occlusion were included. Successful reperfusion was observed in 87.1% and 90-day functional independence in 51.9%. The rate of functional independence decreased gradually with increasing number of recanalization attempts (p < 0.001). In both M2 occlusions and LVO, successful reperfusion within three attempts was associated with greater odds of functional independence, while success at ⩾fourth attempt was not. Patients with ⩾4 attempts exhibited higher rates of symptomatic intracranial hemorrhage in M2 occlusions (6.5% vs 2.7%, p = 0.02) and LVO (7.2% vs 3.5%, p < 0.001). CONCLUSION This study suggests a clinical benefit of successful reperfusion within three recanalization attempts in endovascular therapy for M2 occlusions, which was similar in LVO. Our findings reduce concerns about the risk-benefit ratio of multiple attempts in M2 medium vessel occlusions. DATA ACCESS STATEMENT The data that support the findings of this study are available on reasonable request after approval of the German Stroke Registry (GSR) steering committee. CLINICAL TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT03356392.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Palsson F, Forkert ND, Meyer L, Broocks G, Flottmann F, Maros ME, Bechstein M, Winkelmeier L, Schlemm E, Fiehler J, Gellißen S, Kniep HC. Prediction of tissue outcome in acute ischemic stroke based on single-phase CT angiography at admission. Front Neurol 2024; 15:1330497. [PMID: 38566856 PMCID: PMC10985353 DOI: 10.3389/fneur.2024.1330497] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction In acute ischemic stroke, prediction of the tissue outcome after reperfusion can be used to identify patients that might benefit from mechanical thrombectomy (MT). The aim of this work was to develop a deep learning model that can predict the follow-up infarct location and extent exclusively based on acute single-phase computed tomography angiography (CTA) datasets. In comparison to CT perfusion (CTP), CTA imaging is more widely available, less prone to artifacts, and the established standard of care in acute stroke imaging protocols. Furthermore, recent RCTs have shown that also patients with large established infarctions benefit from MT, which might not have been selected for MT based on CTP core/penumbra mismatch analysis. Methods All patients with acute large vessel occlusion of the anterior circulation treated at our institution between 12/2015 and 12/2020 were screened (N = 404) and 238 patients undergoing MT with successful reperfusion were included for final analysis. Ground truth infarct lesions were segmented on 24 h follow-up CT scans. Pre-processed CTA images were used as input for a U-Net-based convolutional neural network trained for lesion prediction, enhanced with a spatial and channel-wise squeeze-and-excitation block. Post-processing was applied to remove small predicted lesion components. The model was evaluated using a 5-fold cross-validation and a separate test set with Dice similarity coefficient (DSC) as the primary metric and average volume error as the secondary metric. Results The mean ± standard deviation test set DSC over all folds after post-processing was 0.35 ± 0.2 and the mean test set average volume error was 11.5 mL. The performance was relatively uniform across models with the best model according to the DSC achieved a score of 0.37 ± 0.2 after post-processing and the best model in terms of average volume error yielded 3.9 mL. Conclusion 24 h follow-up infarct prediction using acute CTA imaging exclusively is feasible with DSC measures comparable to results of CTP-based algorithms reported in other studies. The proposed method might pave the way to a wider acceptance, feasibility, and applicability of follow-up infarct prediction based on artificial intelligence.
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Affiliation(s)
- Frosti Palsson
- deCODE Genetics Inc., Reykjavik, Iceland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D. Forkert
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Máté E. Maros
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C. Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Beckmann L, Faizy TD, Flottmann F, Fiehler J, Bokemeyer C, Well L, Beitzen-Heineke A, Langer F. Multisite Thrombosis in a Patient with Paroxysmal Nocturnal Hemoglobinuria. Hamostaseologie 2024. [PMID: 38335997 DOI: 10.1055/a-2231-5277] [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: 02/12/2024] Open
Abstract
CASE Paroxysmal nocturnal hemoglobinuria (PNH) is an extremely rare bone marrow disorder caused by acquired mutations in the phosphatidylinositol glycan class A gene, which lead to a partial or total loss of the cellular complement regulators CD55 and CD59.1 In addition to complement-mediated hemolysis and cytopenia, venous and arterial thromboses at multiple and/or unusual sites are a common complication and occur in up to 44% of patients in historic PNH cohorts.1 2.
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Affiliation(s)
- Lennart Beckmann
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Zentrum für Radiologie und Endoskopie, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Zentrum für Radiologie und Endoskopie, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Zentrum für Radiologie und Endoskopie, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Lennart Well
- Zentrum für Radiologie und Endoskopie, Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Antonia Beitzen-Heineke
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Florian Langer
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
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Heinze M, Schell M, Nägele FL, Cheng B, Flottmann F, Fiehler J, Schmidt-Lauber C, Thomalla G. Kidney dysfunction predicts 90 days mortality after stroke thrombectomy independent of cardiovascular risk factors and chronic kidney disease. Eur Stroke J 2024:23969873231224200. [PMID: 38193319 DOI: 10.1177/23969873231224200] [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: 01/10/2024] Open
Abstract
INTRODUCTION Kidney dysfunction (KD) is a risk factor for cerebrovascular events and has been shown to have a detrimental effect on outcome after stroke. We evaluated the influence of KD at admission and pre-existing diagnosis of chronic kidney disease (CKD) before thrombectomy for anterior circulation stroke on functional independence and mortality 90 days after stroke in this cross-sectional study. PATIENTS AND METHODS We included patients with acute ischemic stroke in the anterior circulation treated with thrombectomy at our hospital between June 2015 and May 2022. We analyzed clinical characteristics, laboratory values and pre-existing diagnosis of CKD. KD at admission was defined as glomerular filtration rate (GFR) <60 ml/min/1.73 m2. Outcomes were defined as a modified Rankin Scale Score of 0-2 for functional independence and mortality at 90 days. We fitted multivariate regression analysis to examine the influence of pre-treatment KD and pre-diagnosed CKD on outcome. RESULTS Nine hundred fifty-three patients were included in this analysis (mean age 73.8 years, 54.2% female). KD was present in 31.8%, and patients with KD were older and more often female, presented more often with comorbidities such as arterial hypertension, diabetes, and atrial fibrillation, and were less often independent before the index stroke. In multivariate analysis adjusted for age, independence before the index stroke, diabetes, hypertension, atrial fibrillation, initial NIHSS, thrombolysis treatment, and recanalization outcome, KD on admission had no significant influence on functional independence 90 days after stroke, but predicted mortality with an odds ratio of 1.80 (95% CI 1.23-2.63, p = 0.003). This influence also persisted when controlling for pre-diagnosed CKD (OR 1.60, 95% CI 1.05-2.43, p = 0.027). DISCUSSION KD might function as a surrogate parameter for comorbidity burden and thus increased risk of mortality in this cohort. CONCLUSIONS KD on admission is associated with an 80% higher risk of mortality at 90 days after stroke thrombectomy independent of cardiovascular risk factors and CKD awareness. KD on admission should not exclude patients from thrombectomy but might support prognostic evaluation.
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Affiliation(s)
- Marlene Heinze
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix Leonard Nägele
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Poli S, Mbroh J, Baron JC, Singhal AB, Strbian D, Molina C, Lemmens R, Turc G, Mikulik R, Michel P, Tatlisumak T, Audebert HJ, Dichgans M, Veltkamp R, Hüsing J, Graessner H, Fiehler J, Montaner J, Adeyemi AK, Althaus K, Arenillas JF, Bender B, Benedikt F, Broocks G, Burghaus I, Cardona P, Deb-Chatterji M, Cviková M, Defreyne L, De Herdt V, Detante O, Ernemann U, Flottmann F, García Guillamón L, Glauch M, Gomez-Exposito A, Gory B, Sylvie Grand S, Haršány M, Hauser TK, Heck O, Hemelsoet D, Hennersdorf F, Hoppe J, Kalmbach P, Kellert L, Köhrmann M, Kowarik M, Lara-Rodríguez B, Legris L, Lindig T, Luntz S, Lusk J, Mac Grory B, Manger A, Martinez-Majander N, Mengel A, Meyne J, Müller S, Mundiyanapurath S, Naggara O, Nedeltchev K, Nguyen TN, Nilsson MA, Obadia M, Poli K, Purrucker JC, Räty S, Richard S, Richter H, Schilte C, Schlemm E, Stöhr L, Stolte B, Sykora M, Thomalla G, Tomppo L, van Horn N, Zeller J, Ziemann U, Zuern CS, Härtig F, Tuennerhoff J. Penumbral Rescue by normobaric O = O administration in patients with ischemic stroke and target mismatch proFile (PROOF): Study protocol of a phase IIb trial. Int J Stroke 2024; 19:120-126. [PMID: 37515459 PMCID: PMC10759237 DOI: 10.1177/17474930231185275] [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: 04/27/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023]
Abstract
RATIONALE Oxygen is essential for cellular energy metabolism. Neurons are particularly vulnerable to hypoxia. Increasing oxygen supply shortly after stroke onset could preserve the ischemic penumbra until revascularization occurs. AIMS PROOF investigates the use of normobaric oxygen (NBO) therapy within 6 h of symptom onset/notice for brain-protective bridging until endovascular revascularization of acute intracranial anterior-circulation occlusion. METHODS AND DESIGN Randomized (1:1), standard treatment-controlled, open-label, blinded endpoint, multicenter adaptive phase IIb trial. STUDY OUTCOMES Primary outcome is ischemic core growth (mL) from baseline to 24 h (intention-to-treat analysis). Secondary efficacy outcomes include change in NIHSS from baseline to 24 h, mRS at 90 days, cognitive and emotional function, and quality of life. Safety outcomes include mortality, intracranial hemorrhage, and respiratory failure. Exploratory analyses of imaging and blood biomarkers will be conducted. SAMPLE SIZE Using an adaptive design with interim analysis at 80 patients per arm, up to 456 participants (228 per arm) would be needed for 80% power (one-sided alpha 0.05) to detect a mean reduction of ischemic core growth by 6.68 mL, assuming 21.4 mL standard deviation. DISCUSSION By enrolling endovascular thrombectomy candidates in an early time window, the trial replicates insights from preclinical studies in which NBO showed beneficial effects, namely early initiation of near 100% inspired oxygen during short temporary ischemia. Primary outcome assessment at 24 h on follow-up imaging reduces variability due to withdrawal of care and early clinical confounders such as delayed extubation and aspiration pneumonia. TRIAL REGISTRATIONS ClinicalTrials.gov: NCT03500939; EudraCT: 2017-001355-31.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Jean-Claude Baron
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris, Paris, France
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Carlos Molina
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Guillaume Turc
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris, Paris, France
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences INSERM U1266 Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Robert Mikulik
- Department of Neurology, St. Anne’s University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Patrik Michel
- Neurosciences Cliniques, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, UK
| | - Johannes Hüsing
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
- Landeskrebsregister Nordrhein-Westfalen, Bochum, Germany
| | - Holm Graessner
- Center for Rare Diseases, Eberhard-Karls University, Tubingen, Germany
| | - Jens Fiehler
- Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Joan Montaner
- Vall d’Hebron Institut de Recerca, Neurovascular Research Lab, Barcelona, Spain
| | | | | | | | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Frank Benedikt
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ina Burghaus
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Pere Cardona
- Department of Neurology, Hospital University de Bellvitge, Barcelona, Spain
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
| | - Luc Defreyne
- Department of Vascular and Interventional Radiology, Ghent University Hospital, Ghent, Belgium
| | - Veerle De Herdt
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Olivier Detante
- Neurology, CHU Grenoble Alpes, Grenoble, France
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Monika Glauch
- Center for Rare Diseases, Eberhard-Karls University, Tubingen, Germany
| | - Alexandra Gomez-Exposito
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospital Regional Universitaire de Nancy, Universite de Lorraine, INSERM U1254, Nancy, France
| | - Sylvie Sylvie Grand
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
- Neuroradiology / MRI Department, CHU Grenoble Alpes, Grenoble, France
| | - Michal Haršány
- Department of Neurology, St. Anne’s University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
- International Clinical Research Centre, St. Anne’s University Hospital in Brno, Brno, Czech Republic
| | - Till Karsten Hauser
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Olivier Heck
- Neuroradiology / MRI Department, CHU Grenoble Alpes, Grenoble, France
| | | | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Julia Hoppe
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pia Kalmbach
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Markus Kowarik
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | | | - Loic Legris
- Neurology, CHU Grenoble Alpes, Grenoble, France
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Tobias Lindig
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Steffen Luntz
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Jay Lusk
- Duke University School of Medicine, Durham, NC, USA
| | - Brian Mac Grory
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Andreas Manger
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tubingen, Germany
| | | | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Susanne Müller
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
| | | | - Olivier Naggara
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences INSERM U1266 Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Krassen Nedeltchev
- Department of Neurology, KSA Kantonsspital Aarau and University of Bern, Bern, Switzerland
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Maike A Nilsson
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Michael Obadia
- Department of Neurology and Stroke Center, Hopital fondation Adolphe de Rothschild, Paris, France
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Hardy Richter
- Department of Infectiology, Eberhard-Karls-University, Tuebingen, Germany
| | - Clotilde Schilte
- Department of Anaesthesia and Critical Care, CHU Grenoble Alpes, Grenoble, France
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Stöhr
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Benjamin Stolte
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marek Sykora
- Department of Neurology, St. John’s Hospital, Vienna, Austria
| | - Götz Thomalla
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Noel van Horn
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Zeller
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Christine S Zuern
- Department of Cardiology, Universitatsspital Basel, Basel, Switzerland
| | - Florian Härtig
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tubingen, Germany
| | - Johannes Tuennerhoff
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
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Kniep H, Meyer L, Broocks G, Faizy TD, Bechstein M, Brekenfeld C, Flottmann F, van Horn N, Geest V, Winkelmeier L, Alegiani A, Deb-Chatterji M, Hanning U, Thomalla G, Fiehler J, Gellissen S. Thrombectomy in M2 occlusion compared to M1 occlusion: treatment effects of Thrombolysis In Cerebral Infarction (TICI) 2b and TICI 3 recanalization on functional outcome. J Neurointerv Surg 2023; 15:e438-e445. [PMID: 36990689 PMCID: PMC10803999 DOI: 10.1136/jnis-2022-019898] [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: 11/20/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Emerging data suggest that mechanical thrombectomy (MT) might also be safe and efficient for medium and distal occlusions. This study aims to compare average treatment effects on functional outcome of different degrees of recanalization after MT in patients with M2 occlusion and M1 occlusion. METHODS All patients enrolled in the German Stroke Registry (GSR) between June 2015 and December 2021 were analyzed. Inclusion criteria were stroke with primary M1 occlusion or M2 occlusion, and availability of relevant clinical data. 4259 patients were included, thereof 1353 with M2 occlusion and 2906 with M1 occlusion. Treatment effects were analyzed using double-robust inverse-probability-weighted regression-adjustment (IPWRA) estimators to control for confounding covariates. Binarized endpoint metrics were defined as good outcome with modified Rankin Scale (mRS) ≤2 at 90 days, and linearized endpoint metrics were defined as mRS shift pre-stroke to 90 days. Effects were evaluated for near complete recanalization (Thrombolysis In Cerebral Infarction scale (TICI) 2b) and complete recanalization (TICI 3). RESULTS Treatment effect estimation for TICI ≥2b versus TICI <2b in M2 occlusions showed an increase in the probability of a good outcome from 27% to 47% with a number-needed-to-treat (NNT) of 5. For M1 occlusions the probability of a good outcome increased from 16% to 38% with NNT 4.5. TICI 3 versus TICI 2b increased the probability of a good outcome by 7 percentage points in M1 occlusions; for M2 occlusions the beneficial effect was not significant. CONCLUSIONS Results suggest that successful recanalization with TICI ≥2b versus TICI <2b after MT in M2 occlusions provides significant patient benefit with treatment effects comparable to M1 occlusions. The probability of functional independence increased by 20 percentage points (NNT 5) and stroke-related mRS increase was reduced by 0.9 mRS points. In contrast to M1 occlusions, complete recanalization TICI 3 versus TICI 2b had lower additional beneficial effect.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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10
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Bendszus M, Fiehler J, Subtil F, Bonekamp S, Aamodt AH, Fuentes B, Gizewski ER, Hill MD, Krajina A, Pierot L, Simonsen CZ, Zeleňák K, Blauenfeldt RA, Cheng B, Denis A, Deutschmann H, Dorn F, Flottmann F, Gellißen S, Gerber JC, Goyal M, Haring J, Herweh C, Hopf-Jensen S, Hua VT, Jensen M, Kastrup A, Keil CF, Klepanec A, Kurča E, Mikkelsen R, Möhlenbruch M, Müller-Hülsbeck S, Münnich N, Pagano P, Papanagiotou P, Petzold GC, Pham M, Puetz V, Raupach J, Reimann G, Ringleb PA, Schell M, Schlemm E, Schönenberger S, Tennøe B, Ulfert C, Vališ K, Vítková E, Vollherbst DF, Wick W, Thomalla G. Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet 2023; 402:1753-1763. [PMID: 37837989 DOI: 10.1016/s0140-6736(23)02032-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Recent evidence suggests a beneficial effect of endovascular thrombectomy in acute ischaemic stroke with large infarct; however, previous trials have relied on multimodal brain imaging, whereas non-contrast CT is mostly used in clinical practice. METHODS In a prospective multicentre, open-label, randomised trial, patients with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and a large established infarct indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 were randomly assigned using a central, web-based system (using a 1:1 ratio) to receive either endovascular thrombectomy with medical treatment or medical treatment (ie, standard of care) alone up to 12 h from stroke onset. The study was conducted in 40 hospitals in Europe and one site in Canada. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days, assessed by investigators masked to treatment assignment. The primary analysis was done in the intention-to-treat population. Safety endpoints included mortality and rates of symptomatic intracranial haemorrhage and were analysed in the safety population, which included all patients based on the treatment they received. This trial is registered with ClinicalTrials.gov, NCT03094715. FINDINGS From July 17, 2018, to Feb 21, 2023, 253 patients were randomly assigned, with 125 patients assigned to endovascular thrombectomy and 128 to medical treatment alone. The trial was stopped early for efficacy after the first pre-planned interim analysis. At 90 days, endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better outcome (adjusted common OR 2·58 [95% CI 1·60-4·15]; p=0·0001) and with lower mortality (hazard ratio 0·67 [95% CI 0·46-0·98]; p=0·038). Symptomatic intracranial haemorrhage occurred in seven (6%) patients with thrombectomy and in six (5%) with medical treatment alone. INTERPRETATION Endovascular thrombectomy was associated with improved functional outcome and lower mortality in patients with acute ischaemic stroke from large vessel occlusion with established large infarct in a setting using non-contrast CT as the predominant imaging modality for patient selection. FUNDING EU Horizon 2020.
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Affiliation(s)
- Martin Bendszus
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jens Fiehler
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany; eppdata GmbH, Hamburg, Germany
| | - Fabien Subtil
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France
| | - Susanne Bonekamp
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research-La Paz University Hospital-Universidad Autonoma de Madrid, Madrid, Spain
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Health Science Centre, University of Calgary & Foothills Medical Centre, Calgary, AB, Canada
| | - Antonin Krajina
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Angélique Denis
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France
| | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University Graz, Graz, Austria
| | - Franziska Dorn
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Fabian Flottmann
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Mayank Goyal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Health Science Centre, University of Calgary & Foothills Medical Centre, Calgary, AB, Canada
| | - Jozef Haring
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Christian Herweh
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Silke Hopf-Jensen
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, DIAKO Krankenhaus gGmbH, Flensburg, Germany
| | - Vi Tuan Hua
- Department of Neurology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Kastrup
- Klinik für Neurologie, Klinikum Bremen Mitte, Bremen, Germany
| | - Christiane Fee Keil
- Institut für Neuroradiologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Andrej Klepanec
- Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Egon Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Ronni Mikkelsen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Stefan Müller-Hülsbeck
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, DIAKO Krankenhaus gGmbH, Flensburg, Germany
| | - Nico Münnich
- Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | - Paolo Pagano
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Panagiotis Papanagiotou
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Klinikum Bremen Mitte, Bremen, Germany; Department of Radiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabor C Petzold
- Vascular Neurology Research Group, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany; Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Mirko Pham
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Volker Puetz
- Department of Neurology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Jan Raupach
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | - Gernot Reimann
- Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | | | - Maximilian Schell
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Bjørn Tennøe
- Department of Neuroradiology, Oslo University Hospital, Oslo, Norway
| | - Christian Ulfert
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Kateřina Vališ
- St Anne's University Hospital Brno, Brno, Czech Republic
| | - Eva Vítková
- Department of Neurology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | | | - Wolfgang Wick
- Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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11
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Kniep H, Meyer L, Broocks G, Bechstein M, Guerreiro H, Winkelmeier L, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellißen S. Predictors of functional outcome after thrombectomy for M2 occlusions: a large scale experience from clinical practice. Sci Rep 2023; 13:18740. [PMID: 37907482 PMCID: PMC10618211 DOI: 10.1038/s41598-023-45232-x] [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: 02/18/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023] Open
Abstract
Mechanical thrombectomy (MT) for acute ischemic stroke with medium vessel occlusions is still a matter of debate. We sought to identify factors associated with clinical outcome after MT for M2-occlusions based on data from the German Stroke Registry-Endovascular Treatment (GSR-ET). All patients prospectively enrolled in the GSR-ET from 05/2015 to 12/2021 were analyzed (NCT03356392). Inclusion criteria were primary M2-occlusions and availability of relevant clinical data. Factors associated with excellent/good outcome (modified Rankin scale mRS 0-1/0-2), poor outcome/death (mRS 5-6) and mRS-increase pre-stroke to day 90 were determined in multivariable logistic regression. 1348 patients were included. 1128(84%) had successful recanalization, 595(44%) achieved good outcome, 402 (30%) had poor outcome. Successful recanalization (odds ratio [OR] 4.27 [95% confidence interval 3.12-5.91], p < 0.001), higher Alberta stroke program early CT score (OR 1.25 [1.18-1.32], p < 0.001) and i.v. thrombolysis (OR 1.28 [1.07-1.54], p < 0.01) increased probability of good outcome, while age (OR 0.95 [0.94-0.95], p < 0.001), higher pre-stroke-mRS (OR 0.36 [0.31-0.40], p < 0.001), higher baseline NIHSS (OR 0.89 [0.88-0.91], p < 0.001), diabetes (OR 0.52 [0.42-0.64], p < 0.001), higher number of passes (OR 0.75 [0.70-0.80], p < 0.001) and intracranial hemorrhage (OR 0.26 [0.14-0.46], p < 0.001) decreased the probability of good outcome. Additional predictors of mRS-increase pre-stroke to 90d were dissections, perforations (OR 1.59 [1.11-2.29], p < 0.05) and clot migration, embolization (OR 1.67 [1.21-2.30], p < 0.01). Corresponding to large-vessel-occlusions, younger age, low pre-stroke-mRS, low severity of acute clinical disability, i.v. thrombolysis and successful recanalization were associated with good outcome while diabetes and higher number of passes decreased probability of good outcome after MT in M2 occlusions. Treatment related complications increased probability of mRS increase pre-stroke to 90d.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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12
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Ngo NT, Flottmann F, Iori F, Bonfanti M, Mandaltsi A, Fiehler J, Bester M. Virtual implantation of Derivo Embolization Devices using PreSize Neurovascular software: Accuracy evaluation and size selection comparison study. Interv Neuroradiol 2023:15910199231202272. [PMID: 37807663 DOI: 10.1177/15910199231202272] [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: 10/10/2023] Open
Abstract
BACKGROUND Evaluating the deployed length of flow diverting stents (FDs) to select the optimal device size remains a challenging, yet crucial, task in aneurysm treatment. This study reports on the accuracy of PreSize Neurovascular (Oxford Heartbeat Ltd), a visualization and simulation software for FD intervention planning, in predicting FD deployed length, and on its impact on device size selection. METHODS Imaging data from consecutive patients treated with Derivo Embolization Device (Acandis GmbH) were collected from University Medical Center Hamburg-Eppendorf and retrospectively analyzed. Accuracy evaluation: prediction accuracy was calculated by comparing deployed FD lengths measured from imaging data and simulated by PreSize. Size selection comparison: two Interventional Neuroradiologists (INR1, INR2), blinded to the devices deployed, used PreSize to select the optimal device size (diameter and length). Their choices were compared against the deployed devices selected by conventional planning. RESULTS Among 98 implanted devices, PreSize predicted deployed FD length with a mean accuracy of 94.54% (95% confidence interval [93.72%, 95.35%]). Among 98 aneurysm cases, PreSize-informed device lengths were significantly shorter (Wilcoxon signed-rank test, INR1: W = 394, P < .001, INR2: W = 305, P < .001) by 4.13 and 4.18 mm on average, and up to 20 and 25 mm, for INR1 and INR2, respectively, than the conventionally selected FDs. In 32% of cases, PreSize-informed devices resulted in fewer vessel bends covered by the FD while achieving sufficient aneurysm coverage. CONCLUSIONS PreSize retrospectively predicted deployed FD lengths with high accuracy. Moreover, INRs in this study were more inclined to select shorter stent length in the simulation than they would have done conventionally.
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Affiliation(s)
- Ngoc T Ngo
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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Heitkamp C, Winkelmeier L, Heit JJ, Flottmann F, Thaler C, Kniep H, Broocks G, Meyer L, Geest V, Albers GW, Lansberg MG, Fiehler J, Faizy TD. The negative effect of aging on cerebral venous outflow in acute ischemic stroke. J Cereb Blood Flow Metab 2023; 43:1648-1655. [PMID: 37254736 PMCID: PMC10581231 DOI: 10.1177/0271678x231179558] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 06/01/2023]
Abstract
Cortical venous outflow (VO) represents an imaging biomarker of increasing interest in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). We conducted a retrospective multicenter cohort study to investigate the effect of aging on VO. A total of 784 patients met the inclusion criteria. Cortical Vein Opacification Score (COVES) was used to assess VO profiles on admission CT angiography. Cerebral microperfusion was determined using the hypoperfusion intensity ratio (HIR) derived from perfusion imaging. Arterial collaterals were assessed using the Tan scale. Multivariable regression analysis was performed to identify independent determinants of VO, HIR and arterial collaterals. In multivariable regression, higher age correlated with worse VO (adjusted odds ratio [95% CI]; 0.83 [0.73-0.95]; P = 0.006) and poorer HIR (β coefficient [95% CI], 0.014 [0.005-0.024]; P = 0.002). The negative effect of higher age on VO was mediated by the extent of HIR (17.3%). We conclude that higher age was associated with worse VO in AIS-LVO, partially explained by the extent of HIR reflecting cerebral microperfusion. Our study underlines the need to assess collateral blood flow beyond the arterial system and provides valuable insights into deteriorated cerebral blood supply in elderly AIS-LVO patients.
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Affiliation(s)
- Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Geest
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Winkelmeier L, Faizy TD, Brekenfeld C, Heitkamp C, Broocks G, Bechstein M, Steffen P, Schell M, Gellissen S, Kniep H, Thomalla G, Fiehler J, Flottmann F. Comparison of Thrombolysis In Cerebral Infarction (TICI) 2b and TICI 3 reperfusion in endovascular therapy for large ischemic anterior circulation strokes. J Neurointerv Surg 2023:jnis-2023-020724. [PMID: 37777256 DOI: 10.1136/jnis-2023-020724] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/04/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Landmark thrombectomy trials have provided evidence that selected patients with large ischemic stroke benefit from successful endovascular therapy, commonly defined as incomplete (modified Thrombolysis In Cerebral Infarction (mTICI) 2b) or complete reperfusion (mTICI 3). We aimed to investigate whether mTICI 3 improves functional outcomes compared with mTICI 2b in large ischemic strokes. METHODS This retrospective multicenter cohort study was conducted to compare mTICI 2b versus mTICI 3 in large ischemic strokes in the anterior circulation. Patients enrolled in the German Stroke Registry between 2015-2021 were analyzed. Large ischemic stroke was defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. Patients were matched by final mTICI grade using propensity score matching. Primary outcome was the 90-day modified Rankin Scale (mRS) score. RESULTS After matching, 226 patients were included. Baseline and imaging characteristics were balanced between mTICI 2b and mTICI 3 patients. There was no shift on the mRS favoring mTICI 3 compared with mTICI 2b in large ischemic strokes (adjusted common odds ratio (acOR) 1.12, 95% confidence interval (95% CI) 0.64 to 1.94, P=0.70). The rate of symptomatic intracranial hemorrhage was higher in mTICI 2b than in mTICI 3 patients (12.6% vs 4.5%, P=0.03). Mortality at 90 days did not differ between mTICI 3 and mTICI 2b (33.6% vs 37.2%; adjusted OR 0.69, 95% CI 0.33 to 1.45, P=0.33). CONCLUSIONS In endovascular therapy for large ischemic strokes, mTICI 3 was not associated with better 90-day functional outcomes compared with mTICI 2b. This study suggests that mTICI 2b might be warranted as the final angiographic result, questioning the benefit/risk ratio of additional maneuvers to seek for mTICI 3 in large ischemic strokes. TRIAL REGISTRATION NUMBER NCT03356392.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Steffen
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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15
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Kyselyova AA, Frölich AM, Bester M, Brekenfeld C, Buhk JH, Ding A, Nagl F, Jost TJ, Guerreiro H, Ngo NT, Fiehler J, Flottmann F. Evaluation of intracranial stenting in a simulated training and assessment environment for neuroendovascular procedures. Front Neurol 2023; 14:1247421. [PMID: 37727579 PMCID: PMC10506405 DOI: 10.3389/fneur.2023.1247421] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/24/2023] [Indexed: 09/21/2023] Open
Abstract
Purpose Given the inherent complexity of neurointerventional procedures and the associated risks of ionizing radiation exposure, it is crucial to prioritize ongoing training and improve safety protocols. The aim of this study is to assess a training and evaluation in-vitro environment using a vascular model of M1 stenosis, within a clinical angiography suite, without relying on animal models or X-ray radiation. Materials and methods Using a transparent model replicating M1 stenosis, we conducted intracranial stenting procedures with four different setups (Gateway & Wingspan, Gateway & Enterprise, Neurospeed & Acclino, and Pharos Vitesse). A video camera was integrated with the angiography system's monitor for real-time visualization, while a foot switch was employed to simulate live fluoroscopy. Three neuroradiologists with varying levels of expertise performed each procedure for three times. The total duration of fluoroscopy as well as the time from passing the stenosis with the wire to completion of the procedure were recorded using a dedicated software designed for this experimental setup. Results Compared to the Gateway & Wingspan procedure, the total fluoroscopy time reduced significantly with the Gateway & Enterprise, Neurospeed & Acclino, and Pharos Vitesse procedures by 51.56 s, 111.33 s, and 144.89 s, respectively (p < 0.001). Additionally, physicians with under 2 years and over 5 years of experience reduced FT by 62.83 s and 106.42 s, respectively, (p < 0.001), compared to a novice physician. Similar trends were noted for the time of wire distal to stenosis, with significant reductions for Neurospeed & Acclino and Pharos Vitesse compared to both Gateway & Wingspan as well as Gateway & Enterprise (all p < 0.001). Conclusion Procedures requiring wire exchange maneuvers exhibited nearly twice the fluoroscopy time in comparison to balloon-mounted stenting or stent-placement via PTA balloon catheters. The more experienced neuroradiologist demonstrated significantly quicker performance in line with expectations in a real-life clinical setting, when compared to the less experienced interventionalist. This in-vitro setup allowed the evaluation of alternative technical approaches and differences in experience of operators without the use of animal models or X-ray. The setup combines advantages of simulators and silicone vessel models in a realistic working environment.
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Affiliation(s)
- Anna A. Kyselyova
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas M. Frölich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, Asklepios Hospitals St. Georg and Wandsbek, Hamburg, Germany
| | - Andreas Ding
- Acandis, Acandis GmbH & Co. KG, Pforzheim, Germany
| | - Frank Nagl
- Acandis, Acandis GmbH & Co. KG, Pforzheim, Germany
| | | | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ngoc Tuan Ngo
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Meyer L, Politi M, Alexandrou M, Roth C, Kastrup A, Mpotsaris A, Hanning U, Flottmann F, Brekenfeld C, Deb-Chatterji M, Thomalla G, Kniep H, Faizy TD, Bechstein M, Broocks G, Herzberg M, Feil K, Kellert L, Dorn F, Zeleňák K, Fiehler J, Papanagiotou P. Endovascular treatment of acute tandem lesions in patients with mild anterior circulation stroke. J Neurointerv Surg 2023; 15:e136-e141. [PMID: 36028317 DOI: 10.1136/jnis-2022-019239] [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: 06/03/2022] [Accepted: 08/06/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND In patients with mild strokes the risk-benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice. METHODS Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH). RESULTS A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59-76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2-5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8-10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1-9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5). CONCLUSIONS EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
- Interventional Radiology Unit, Evangelismos General Hospital, Athens, Greece
| | - Maria Alexandrou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Christian Roth
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Anastasios Mpotsaris
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moriz Herzberg
- Department of Radiology, University Hospital Würzburg, Würzburg, Germany
- Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
| | - Katharina Feil
- Department of Neurology, Ludwig Maximilians Universität, München, Germany
- Department of Neurology and Stroke, Eberhard-Karls University, Tübingen, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians Universität, München, Germany
| | - Franziska Dorn
- Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Kamil Zeleňák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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17
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Bay B, Gloyer NO, Remmel M, Schell M, Zelenak K, Seiffert M, Brunner FJ, Clemmensen P, Reichenspurner H, Blankenberg S, Thomalla G, Fiehler J, Conradi L, Waldeyer C, Flottmann F. Mechanical thrombectomy in ischemic stroke after cardiovascular procedures: a propensity-matched cohort analysis. J Neurointerv Surg 2023; 15:e129-e135. [PMID: 35985838 DOI: 10.1136/jnis-2022-019152] [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: 05/12/2022] [Accepted: 08/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Stroke after a cardiovascular procedure (CVP) is a devastating complication adversely affecting outcome. Mechanical thrombectomy (MT) has not been investigated systematically in this population. OBJECTIVE To carry out a retrospective study in patients undergoing MT for early stroke after CVP, aiming to further characterize this cohort of patients, and to evaluate the efficacy, safety, procedural characteristics, and outcome of MT. METHODS A single-center stroke registry of patients who received MT was analyzed. Baseline and procedural parameters, mortality, functional outcome, recanalization rates, and complications were evaluated. Propensity score matching was carried out, identifying a control cohort with non-periprocedural large vessel occlusion (LVO). RESULTS Overall 913 patients were included (mean age 73.0 (±13.0) years, 52.5% female, median National Institutes of Health Stroke Scale score 15 (10-19)). Eleven patients with a LVO after a recent (<30 days postoperatively) CVP were identified (n=3 transcatheter aortic valve and n=1 surgical aortic valve replacements (SAVR), n=3 coronary bypass grafting (CABG) surgeries, n=2 SAVR+CABG, and n=2 aortic surgeries). After matching, 8 patients in the CVP group were compared with 16 patients in the matched cohort. Comparable rates of reperfusion were achieved. Time from symptom onset to groin puncture (171.5 min (136.3, 178.3) vs 284.0 min (215.0, 490.5); p=0.039), as well as recanalization (195.0 min (146.0, 201.0) vs 419.0 min (274.0, 613.0); p=0.028) was faster in the CVP group. However, this was not reflected by an improved outcome (modified Rankin Scale score after 90 days: 5.5 (3.3, 6.0) vs 5.0 (4.0, 6.0), mortality after 90 days 50.0% vs 37.5%). Complications did not differ between the groups. CONCLUSIONS Use of MT for LVO stroke in patients after a recent CVP is a safe and efficient treatment in comparison with patients with a non-periprocedural LVO undergoing MT.
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Affiliation(s)
- Benjamin Bay
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils-Ole Gloyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marko Remmel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamil Zelenak
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Moritz Seiffert
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian J Brunner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Peter Clemmensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Faculty of Health Sciences, Department of Regional Health Research, University of Southern Denmark and Nykoebing Falster Hospital, Odense, Denmark
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Waldeyer
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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18
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Schulze-Zachau V, Brehm A, Ntoulias N, Krug N, Tsogkas I, Blackham KA, Möhlenbruch MA, Jesser J, Cervo A, Kreiser K, Althaus K, Maslias E, Michel P, Saliou G, Riegler C, Nolte CH, Maier I, Jamous A, Rautio R, Ylikotila P, Fargen KM, Wolfe SQ, Castellano D, Boghi A, Kaiser DPO, Cuberi A, Kirschke JS, Schwarting J, Limbucci N, Renieri L, Al Kasab S, Spiotta AM, Fragata I, Rodriquez-Ares T, Maurer CJ, Berlis A, Moreu M, López-Frías A, Pérez-García C, Commodaro C, Pileggi M, Mascitelli J, Giordano F, Casagrande W, Purves CP, Bester M, Flottmann F, Kan PT, Edhayan G, Hofmeister J, Machi P, Kaschner M, Weiss D, Katan M, Fischer U, Psychogios MN. Incidence and outcome of perforations during medium vessel occlusion compared with large vessel occlusion thrombectomy. J Neurointerv Surg 2023:jnis-2023-020531. [PMID: 37524518 DOI: 10.1136/jnis-2023-020531] [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] [Received: 05/04/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Vessel perforation during thrombectomy is a severe complication and is hypothesized to be more frequent during medium vessel occlusion (MeVO) thrombectomy. The aim of this study was to compare the incidence and outcome of patients with perforation during MeVO and large vessel occlusion (LVO) thrombectomy and to report on the procedural steps that led to perforation. METHODS In this multicenter retrospective cohort study, data of consecutive patients with vessel perforation during thrombectomy between January 1, 2015 and September 30, 2022 were collected. The primary outcomes were independent functional outcome (ie, modified Rankin Scale 0-2) and all-cause mortality at 90 days. Binomial test, chi-squared test and t-test for unpaired samples were used for statistical analysis. RESULTS During 25 769 thrombectomies (5124 MeVO, 20 645 LVO) in 25 stroke centers, perforation occurred in 335 patients (1.3%; mean age 72 years, 62% female). Perforation occurred more often in MeVO thrombectomy (2.4%) than in LVO thrombectomy (1.0%, p<0.001). More MeVO than LVO patients with perforation achieved functional independence at 3 months (25.7% vs 10.9%, p=0.001). All-cause mortality did not differ between groups (overall 51.6%). Navigation beyond the occlusion and retraction of stent retriever/aspiration catheter were the two most common procedural steps that led to perforation. CONCLUSIONS In our cohort, perforation was approximately twice as frequent in MeVO than in LVO thrombectomy. Efforts to optimize the procedure may focus on navigation beyond the occlusion site and retraction of stent retriever/aspiration catheter. Further research is necessary in order to identify thrombectomy candidates at high risk of intraprocedural perforation and to provide data on the effectiveness of endovascular countermeasures.
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Affiliation(s)
- Victor Schulze-Zachau
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Nikolaos Ntoulias
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Nadja Krug
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Ioannis Tsogkas
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Kristine Ann Blackham
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Markus A Möhlenbruch
- Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Amedeo Cervo
- Neuroradiology Department, Niguarda Hospital, Milan, Italy
| | - Kornelia Kreiser
- Radiology and Neuroradiology Clinic, RKU - Universitäts- und Rehabilitationskliniken Ulm gGmbH, Ulm, Germany
| | | | - Errikos Maslias
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- UNIL - Université de Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- UNIL - Université de Lausanne, Lausanne, Switzerland
| | - Guillaume Saliou
- UNIL - Université de Lausanne, Lausanne, Switzerland
- Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ala Jamous
- Department of Diagnostic & Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Riitta Rautio
- Department of Radiology, Turku University Hospital, Turku, Finland
| | | | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Davide Castellano
- Department of Interventional Radiology and Neuroradiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Andrea Boghi
- Department of Interventional Radiology and Neuroradiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Daniel P O Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ani Cuberi
- Department of Radiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan S Kirschke
- Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Julian Schwarting
- Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Nicola Limbucci
- Department of Neurovascular Intervention, Azienda Ospedaliero Universitaria Careggio, Florence, Italy
| | - Leonardo Renieri
- Department of Neurovascular Intervention, Azienda Ospedaliero Universitaria Careggio, Florence, Italy
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central EPE, Lisbon, Portugal
- NOVA Medical School, Lisbon, Portugal
| | - Tania Rodriquez-Ares
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central EPE, Lisbon, Portugal
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Manuel Moreu
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Alfonso López-Frías
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Carlos Pérez-García
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Christian Commodaro
- Diagnostic and Interventional Neuroradiology Department, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Marco Pileggi
- Diagnostic and Interventional Neuroradiology Department, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Justin Mascitelli
- Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli, Naples, Italy
| | - Walter Casagrande
- Neurosurgery Department, Hospital General de Agudos Juan A Fernandez, Buenos Aires, Argentina
| | - Cynthia P Purves
- Neurosurgery Department, Hospital General de Agudos Juan A Fernandez, Buenos Aires, Argentina
| | - Maxim Bester
- Diagnostic and Interventional Neuroradiology Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Diagnostic and Interventional Neuroradiology Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter T Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Gautam Edhayan
- Department of Radiology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jeremy Hofmeister
- Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Paolo Machi
- Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Weiss
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Mira Katan
- Neurology Clinic, University Hospital Basel, Basel, Switzerland
| | - Urs Fischer
- Neurology Clinic, University Hospital Basel, Basel, Switzerland
| | - Marios-Nikos Psychogios
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
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19
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Kniep H, Meyer L, Broocks G, Bechstein M, Heitkamp C, Winkelmeier L, Faizy T, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellißen S. Thrombectomy for M2 Occlusions: Predictors of Successful and Futile Recanalization. Stroke 2023. [PMID: 37439204 DOI: 10.1161/strokeaha.123.043285] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Patient-specific factors associated with successful recanalization in mechanical thrombectomy (MT) have been evaluated for acute ischemic stroke with large vessel occlusion. However, MT for M2 occlusions is still a matter of debate, and predictors of successful and futile recanalization have not been assessed in detail. We sought to identify predictors of recanalization success in patients with M2 occlusions undergoing MT based on large-scale clinical data. METHODS All patients prospectively enrolled in the German Stroke Registry (May, 2015 to December, 2021) were screened (N=13 082). Inclusion criteria for the complete case analysis were isolated M2 occlusions. Standard descriptive statistics and multivariable logistic regression analysis were used to identify factors associated with successful recanalization (Thrombolysis in Cerebral Infarction [TICI]≥2b), complete recanalization (TICI=3) and futile recanalization (TICI≥2b with 90-day modified Rankin Scale [mRS] score >2). RESULTS One thousand two hundred ninety-four patients were included, thereof 439 (33.9%) with TICI=2b and 643 (49.7%) with TICI=3. Five hundred sixty-nine (44%) patients had good functional outcome (90-day mRS score ≤2). In multivariable logistic regression, general anesthesia (adjusted odds ratio [aOR], 1.47 [95% CI, 1.05-2.09]; P<0.05) was associated with higher probability of TICI≥2b while intraprocedural change from local to general anesthesia (aOR, 0.49 [0.26-0.95]; P<0.05) and higher pre-mRS (aOR, 0.75 [0.67-0.85]; P<0.001) lowered probability of successful recanalization. Futile recanalization was associated with higher age (aOR, 1.05 [1.04-1.07]; P<0.001), higher prestroke mRS (aOR, 3.12 [2.49-3.91]; P<0.001), higher NIHSS at admission (aOR, 1.11 [1.08-1.14]; P<0.001), diabetes (aOR, 1.96 [1.38-2.8]; P<0.001), higher number of passes (aOR, 1.29 [1.14-1.46]; P<0.001), and adverse events (aOR, 1.82 [1.2-2.74]; P<0.01). Higher Alberta Stroke Program Early CT Score (aOR, 0.85 [0.76-0.94]; P<0.01) and IV thrombolysis (aOR, 0.71 [0.52-0.97]; P<0.05) reduced risk of futile recanalization. CONCLUSIONS In patients with M2 occlusions, successful recanalization was significantly associated with general anesthesia and low prestroke mRS, while intraprocedural change from conscious sedation to general anesthesia increased risk of unsuccessful recanalization, presumably caused by difficult anatomy and movement of patients in these cases. Futile recanalization was associated with severe prestroke mRS, comorbidity diabetes, number of passes and adverse events during treatment. IV thrombolysis reduced the risk of futile recanalization.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., G.T.)
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany (M.D.-C.)
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany (A.A.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., G.T.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
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20
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Faizy TD, Broocks G, Heit JJ, Kniep H, Flottmann F, Meyer L, Sporns P, Hanning U, Kaesmacher J, Deb-Chatterji M, Vollmuth P, Lansberg MG, Albers GW, Fischer U, Wintermark M, Thomalla G, Fiehler J, Winkelmeier L. Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion. JAMA Netw Open 2023; 6:e2310213. [PMID: 37126350 PMCID: PMC10152307 DOI: 10.1001/jamanetworkopen.2023.10213] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Importance Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. Objective To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. Design, Setting, and Participants Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. Interventions Mechanical thrombectomy with or without IVT. Main Outcomes and Measures Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. Results After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). Conclusions and Relevance These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.
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Affiliation(s)
- Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, University Medical Center Heidelberg, Heidelberg, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Gregory W Albers
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Urs Fischer
- Department of Neurology, University Medical Center Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Barow E, Probst AC, Pinnschmidt H, Heinze M, Jensen M, Rimmele DL, Flottmann F, Broocks G, Fiehler J, Gerloff C, Thomalla G. Effect of Comorbidity Burden and Polypharmacy on Poor Functional Outcome in Acute Ischemic Stroke. Clin Neuroradiol 2023; 33:147-154. [PMID: 35831611 PMCID: PMC10014774 DOI: 10.1007/s00062-022-01193-8] [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] [Received: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Comorbidities and polypharmacy are risk factors for worse outcome in stroke. However, comorbidities and polypharmacy are mostly studied separately with various approaches to assess them. We aimed to analyze the impact of comorbidity burden and polypharmacy on functional outcome in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). METHODS Acute ischemic stroke patients with large vessel occlusion (LVO) treated with MT from a prospective observational study were analyzed. Relevant comorbidity burden was defined as a Charlson Comorbidity Index (CCI) score ≥ 2, polypharmacy as the intake of ≥ 5 medications at time of stroke onset. Favorable outcome was a score of 0-2 on the modified Rankin scale at 90 days after stroke. The effect of comorbidity burden and polypharmacy on favorable outcome was studied via multivariable regression analysis. RESULTS Of 903 patients enrolled, 703 AIS patients (mean age 73.4 years, 54.9% female) with anterior circulation LVO were included. A CCI ≥ 2 was present in 226 (32.1%) patients, polypharmacy in 315 (44.8%) patients. Favorable outcome was less frequently achieved in patients with a CCI ≥ 2 (47, 20.8% vs. 172, 36.1%, p < 0.001), and in patients with polypharmacy (69, 21.9% vs. 150, 38.7%, p < 0.001). In multivariable regression analysis including clinical covariates, a CCI ≥ 2 was associated with lower odds of favorable outcome (odds ratio, OR 0.52, 95% confidence interval, 95% CI 0.33-0.82, p = 0.005), while polypharmacy was not (OR 0.81, 95% CI 0.52-1.27, p = 0.362). CONCLUSION Relevant comorbidity burden and polypharmacy are common in AIS patients with LVO, with comorbidity burden being a risk factor for poor outcome.
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Affiliation(s)
- Ewgenia Barow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Ann-Cathrin Probst
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Hans Pinnschmidt
- Institut für Medizinische Biometrie und Epidemiologie, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Heinze
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - David Leander Rimmele
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Marto JP, Strambo D, Ntaios G, Nguyen TN, Herzig R, Czlonkowska A, Demeestere J, Mansour OY, Salerno A, Wegener S, Baumgartner P, Cereda CW, Bianco G, Beyeler M, Arnold M, Carrera E, Machi P, Altersberger V, Bonati L, Gensicke H, Bolognese M, Peters N, Wetzel S, Magriço M, Ramos JN, Sargento-Freitas J, Machado R, Maia C, Machado E, Nunes AP, Ferreira P, Pinho e Melo T, Dias MC, Paula A, Correia MA, Castro P, Azevedo E, Albuquerque L, Alves JN, Ferreira-Pinto J, Meira T, Pereira L, Rodrigues M, Araujo AP, Rodrigues M, Rocha M, Pereira-Fonseca Â, Ribeiro L, Varela R, Malheiro S, Cappellari M, Zivelonghi C, Sajeva G, Zini A, Gentile M, Forlivesi S, Migliaccio L, Sessa M, La Gioia S, Pezzini A, Sangalli D, Zedde M, Pascarella R, Ferrarese C, Beretta S, Diamanti S, Schwarz G, Frisullo G, Marcheselli S, Seners P, Sabben C, Escalard S, Piotin M, Maïer B, Charbonnier G, Vuillier F, Legris L, Cuisenier P, Vodret FR, Marnat G, Liegey JS, Sibon I, Flottmann F, Broocks G, Gloyer NO, Bohmann FO, Schaefer JH, Nolte C, Audebert HJ, Siebert E, Sykora M, Lang W, Ferrari J, Mayer-Suess L, Knoflach M, Gizewski ER, Stolp J, Stolze LJ, Coutinho JM, Nederkoorn P, van den Wijngaard I, De Meris J, Lemmens R, De Raedt S, Vandervorst F, Rutgers MP, Guilmot A, Dusart A, Bellante F, Calleja-Castaño P, Ostos F, González-Ortega G, Martín-Jiménez P, García-Madrona S, Cruz-Culebras A, Vera R, Matute MC, Fuentes B, Alonso-de-Leciñana M, Rigual R, Díez-Tejedor E, Perez-Sanchez S, Montaner J, Díaz-Otero F, Pérez-de-la-Ossa N, Flores-Pina B, Muñoz-Narbona L, Chamorro A, Rodríguez-Vázquez A, Renú A, Ayo-Martin O, Hernández-Fernández F, Segura T, Tejada-Meza H, Sagarra-Mur D, Serrano-Ponz M, Hlaing T, See I, Simister R, Werring D, Kristoffersen ES, Nordanstig A, Jood K, Rentzos A, Šimůnek L, Krajíčková D, Krajina A, Mikulik R, Cviková M, Vinklárek J, Školoudík D, Roubec M, Hurtikova E, Hrubý R, Ostry S, Skoda O, Pernicka M, Jurak L, Eichlová Z, Jíra M, Kovar M, Panský M, Mencl P, Palouskova H, Tomek A, Janský P, Olšerová A, Sramek M, Havlicek R, Malý P, Trakal L, Fiksa J, Slovák M, Karlinski MA, Nowak M, Sienkiewicz-Jarosz H, Bochynska A, Wrona P, Homa T, Sawczynska K, Slowik A, Wlodarczyk E, Wiacek M, Tomaszewska-Lampart I, Sieczkowski B, Bartosik-Psujek H, Bilik M, Bandzarewicz A, Dorobek M, Zielinska-Turek J, Nowakowska-Kotas M, Obara K, Urbanowski P, Budrewicz S, Guziński M, Świtońska M, Rutkowska I, Sobieszak-Skura P, Labuz-Roszak BM, Debiec A, Staszewski J, Stępień A, Zwiernik J, Wasilewski G, Tiu C, Terecoasă EO, Radu RA, Negrila A, Dorobat B, Panea C, Tiu V, Petrescu S, Ozdemir A, Mahmoud M, El-Samahy H, Abdelkhalek H, Al-Hashel J, Ismail II, Salmeen A, Ghoreishi A, Sabetay SI, Gross H, Klein P, Abdalkader M, Jabbour P, El Naamani K, Tjoumakaris S, Abbas R, Mohamed GA, Chebl A, Min J, Hovingh M, Tsai JP, Khan M, Nalleballe K, Onteddu S, Masoud H, Michael M, Kaur N, Maali L, Abraham MG, Khandelwal P, Bach I, Ong M, Babici D, Khawaja AM, Hakemi M, Rajamani K, Cano-Nigenda V, Arauz A, Amaya P, Llanos N, Arango A, Vences MÁ, Barrientos Guerra JD, Caetano R, Martins RT, Scollo SD, Yalung PM, Nagendra S, Gaikwad A, Seo KD, Georgiopoulos G, Nogueira RG, Michel P. Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry. Neurology 2023; 100:e739-e750. [PMID: 36351814 PMCID: PMC9969910 DOI: 10.1212/wnl.0000000000201537] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/23/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES COVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19. METHODS This was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS Of a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION Patients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis. TRIAL REGISTRATION INFORMATION The study was registered under ClinicalTrials.gov identifier NCT04895462.
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Affiliation(s)
- João Pedro Marto
- Department of Neurology (J.P.M., M.M.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal; Stroke Centre (D.S., A.S., P.M.), Neurology Service, Department of Neurological Sciences, Lausanne University Hospital, Switzerland; Department of Internal Medicine (G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Neurology, Radiology (T.N.N.), Boston Medical Center, Boston University School of Medicine, MA; Department of Neurology (R.H., L.S., D.K.), Comprehensive Stroke Centre, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czech Republic; 2nd Department of Neurology (A.C., M.A.K., M.N.), Institute of Psychiatry and Neurology, Warsaw, Poland; Neurology Department (J.D., R.L.), Leuven University Hospital, Belgium; Alexandria University Hospitals and Affiliated Stroke Network (O.Y.M.), Egypt; Department of Neurology (S.W., P.B.), University Hospital of Zurich, Switzerland; Stroke Center (C.W.C., G.B.), Neurocenter of Southern Switzerland, EOC, Lugano; Stroke Center (M.B, M.A.), Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Switzerland; Stroke Centre (E.C.), Geneva University Hospital, Switzerland; Department of Neuroradiology (P.M.), Geneva University Hospital, Switzerland; Stroke Centre (V.A, L.B., H.G.), University Hospital Basel and University of Basel, Switzerland; Stroke Centre (M.B.), Kantonsspital Lucerne, Switzerland; Stroke Centre (N.P., S.W.), Hirslanden Hospital, Zurich, Switzerland; Department of Neuroradiology (J.N.R.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal; Department of Neurology (J.S.-F., R.M., C.M.), Centro Hospitalar Universitário de Coimbra, Portugal; Department of Neuroradiology (E.M.), Centro Hospitalar Universitário de Coimbra, Portugal; Stroke Unit (A.P.N., P.F.), Hospital de São José, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal; Stroke Unit (T.P.e.M., M.C.D., A.P.), Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Department of Neuroradiology (M.A.C.), Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Department of Neurology (P.C., E.A.), Centro Hospitalar Universitário São João, Porto, Portugal; Department of Neuroradiology (L.A.), Centro Hospitalar Universitário São João, Porto, Portugal; Departments of Neurology (J.N.A., J.F.-P.), and Neuroradiology (T.M.), Hospital de Braga, Portugal; Department of Neurology (L.P., M.R.), Hospital Garcia de Orta, Almada, Portugal; Department of Neuroradiology (A.P.A., M.R.), Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal; Department of Neurology (M.R.), Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal; Department of Neurology (A.P.-F, L.R.), Unidade Local de Saúde de Matosinhos, Portugal; Department of Neurology (R.V., S.M.), Centro Hospitalar Universitário do Porto, Portugal; Stroke Unit (M.C., C.Z.), Azienda Ospedaliera Universitaria Integrata, Verona, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z., M.G., S.F., L.M.), Department of Neurology and Stroke Centre, Maggiore Hospital, Bologna, Italy; Department of Neurology (M.S., S.L.G.), ASST Papa Giovanni XXIII, Bergamo, Italy; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia, Italy; Department of Neurology and Stroke Unit (D.S.), Azienda Socio Sanitaria Territoriale, Lecco, Italy; Neurology Unit (M.Z.), Stroke Unit, Azienda Unità Sanitaria-IRCCS di Reggio Emilia, Italy; Neuroradiology Unit (R.P.), Azienda Unità Sanitaria-IRCCS di Reggio Emilia, Italy; Department of Neurology (C.F., S.B., S.D.), San Gerardo Hospital, Department of Medicine and Surgery and Milan Centre for Neuroscience, University of Milano Bicocca, Monza, Italy; Stroke Unit (G.S.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Neurology (G.F.), Policlinico Universitario Agostino Gemelli, Rome, Italy; Emergency Neurology and Stroke Unit (S.M.), IRCCS Humanitas Clinical and Research Center, Rozzano, Italy; Department of Neurology (C.S., S.E.), Hôpital Fondation Ade Rothschild, Paris, France; Department of Interventional Neuroradiology (M.P., B.M.), Hôpital Fondation Ade Rothschild, Paris, France; Department of Interventional Neuroradiology (G.C., F.V.), Centre Hospitalier Régional Universitaire, Hôpital Jean Minjoz, Besançon, France; Neurology (F.L., P.C, F.R.V.), Stroke Unit, Centre Hospitalier Universitaire, Grenoble Alpes, France; Department of Interventional and Diagnostic Neuroradiology (J.-S.L., I.S.), Bordeaux University Hospital, France; Department of Diagnostic and Interventional Neuroradiology (F.F, G.B., N.-O.G.), University Medical Center-Hamburg-Eppendorf, Germany; Department of Neurology (F.O.B., J.H.S.), University Hospital Frankfurt, Goethe University, Germany; Department of Neurology and Centre for Stroke Research (H.J.A.), Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Germany; Department of Neuroradiology (E.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (M.S, W.L., J.F.), St. John's Hospital, Vienna, Austria; Departments of Neurology (L.M.-S., M.K.), and Neuroradiology (E.R.G.), Medical University of Innsbruck, Austria; Department of Neurology (J.S., L.J.S., J.M.C.), Amsterdam University Medical Centers, Netherlands; Department of Neurology (I.v.d.W., J.d.M.), Haaglanden Medical Centre, Hague and Department of Radiology, Leiden University Medical Centre, Netherlands; Department of Neurology (S.D.R., F.V.), Universitair Ziekenhuis Brussel, Centre for Neurosciences, Vrije Universiteit Brussel, Belgium; Department of Neurology (M.P.R, A.G.), Stroke Unit, Europe Hospitals, Brussels, Belgium; Department of Neurology (A.D., F.B.), Centre Hospitalier Universitaire de Charleroi, Belgium; Department of Neurology and Stroke Centre (P.C.-C., F.O., P.M.-J.), Hospital Universitario de OctubreInstituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain; Department of Neurology and Stroke Centre (A.C.-C., R.V., M.C.M.), Hospital Universitario Ramón y Cajal, Ramon y Cajal Institute for Health Research (IRYCIS), Madrid, Spain; Department of Neurology and Stroke (B.F, M.A.d.L., R.R., E.D.D.), Centre Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Spain; Department of Neurology (S.P.-S., J.M.), Hospital Universitario Virgen Macarena, Seville, Spain; Stroke Centre (F.D-.O.), Hospital General Universitario Gregorio Marañón, Madrid, Spain; Stroke Unit (B.F.-P., J.M.-N.), Germans Trias Hospital, Barcelona, Spain; Department of Neurology (A.C, A.R.-V., A.R), Comprehensive Stroke Centre, Hospital Clinic from Barcelona, Spain; Department of Neurology (O.A.-M, F.H.-F.), Complejo Hospitalario Universitario de Albacete; Stroke Unit (H.T.-M.), Department of Neurology, and Interventional Neuroradiology Unit, Hospital Universitario Miguel Servet, Spain; Stroke Unit (D.S.-M, M.F.P.), Department of Neurology, Hospital Universitario Miguel Servet, Spain; Stroke and Geriatric Medicine (T.H.), Aintree University Hospital, United Kingdom; Comprehensive Stroke Service (I.S., R.S.), University College London Hospitals NHS Foundation Trust and Stroke Research Centre, University College London, United Kingdom.; University College London (D.W.), Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (E.S.K.), Akershus University Hospital, Lørenskog and Department of General Practice, University of Oslo, Norway; Department of Clinical Neuroscience (A.N, K.J.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology (A.N, K.J.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Department of Radiology (A.R.), Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg and Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Department of Radiology (A.K.), Comprehensive Stroke Centre, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czech Republic; International Clinical Research Centre (R.M., M.C., J.V.) and Department of Neurology, St. Anne´s University Hospital and Faculty of Medicine at Masaryk University, Brno, Czech Republic; Center for Health Research (D.S., M.R, E.H.), Faculty of Medicine, University of Ostrava, Czech Republic; Department of Neurology (R.H, S.V.), České Budějovice Hospital, Czech Republic; Department of Neurology (O.S., M.P.), Jihlava Hospital, Czech Republic; Neurocenter (L.J., Z.E., M.J.), Regional Hospital Liberec, Czech Republic; Cerebrovascular Centre (M.K., M.P., P.M.), Na Homolce Hospital, Prague, Czech Republic; Department of Neurology (H.P.), Karviná Miners Hospital Inc., Czech Republic; Cerebrovascular Centre (A.T, P.J, A.O.), University Hospital in Motol, Prague, Czech Republic; Cerebrovascular Centre (M.S., R.H, P.M., L.T.), Central Military Hospital, Prague, Czech Republic; Cerebrovascular Centre (J.F., M.S.), General University Hospital, Prague, Czech Republic; 1th Department of Neurology (H.S.-J, A.B.), Institute of Psychiatry and Neurology, Warsaw, Poland; Department of Neurology (P.W, T.H., K.S., A.S), University Hospital, Jagiellonian University, Cracow, Poland; Department of Neurology (M.W., L.T.-L., B.S.), Institute of Medical Sciences, Medical College of Rzeszow University, Poland; Department of Neurology and Stroke (M.B, A.B.), St. John Paul II Western Hospital, Grodzisk Mazowiecki, Poland; Department of Neurology (M.D, J.Z.), Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland; Departments of Neurology (M.N.-K., K.O., P.U.), and Radiology (M.G.), Wroclaw Medical University, Poland; Department of Neurosurgery and Neurology (M.S.), Nicolaus Copernicus University in Torun Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland; Stroke Intervention Centre (I.R., P.S.-S.), Department of Neurosurgery and Neurology, Jan Biziel University Hospital, Bydgoszcz, Poland; Department of Neurology (B.M.L.-R.), Institute of Medical Sciences, University of Opole, Poland; Clinic of Neurology (A.D., J.S., A.S.), Military Institute of Medicine, Warsaw, Poland; Department of Neurology (J.Z.), University of Warmia and Mazury, Olsztyn, Poland; Department of Radiology (C.W.), Provincial Specialist Hospital, Olsztyn, Poland; Department of Neurology (C.T., E.O.T., R.A.R., A.N.), University Emergency Hospital Bucharest, University of Medicine and Pharmacy "Carol Davila", Romania; Department of Radiology (B.D.), University Emergency Hospital Bucharest, Romania; Department of Neurology and Stroke Unit (C.P, V.T, S.P.), Elias University Emergency Hospital, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania; Department of Neurology (A.O.), Eskisehir Osmangazi University, Turkey; Ain Shams University Affiliated Saudi German Hospital (M.M., H.E.-S.), Egypt; Neuropsychiatry Department (H.A.), Tanta University, Egypt; Department of Neurology (J.A.-H.), Ibn Sina Hospital, Kuwait; Department of Neurology (I.I.I.), Jaber Al-Ahmad Hospital, Kuwait; Department of Neurology (A.G.), School of Medicine, Zanjan University of Medical Sciences, Iran; Stroke Unit (S.I.S.), Neurology Department, Hillel Yaffe Medical Center, Hadera, Israel; Department of Neurosurgery (P.J., K.E.N, S.T., R.A.), Thomas Jefferson University Hospital, PA; Departments of Radiology (G.A.M., P.G.N.), Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA; Department of Neurology (A.C.), Henry Ford Hospital, Detroit, MI; Comprehensive Stroke Centre and Department of Neurosciences (J.M., M.H., M.K.), Spectrum Health and Michigan State University; Department of Neurology (K.N., S.O.), University of Arkansas for Medical Sciences, Little Rock, AR; Department of Neurology (M.K.), Upstate University Hospital, NY; Department of Neurology (L.M., M.G.A.), University of Kansas Medical Centre; Endovascular Neurological Surgery and Neurology (P.K., I.B, M.O., M.B.), Rutgers, The State University of New Jersey, Newark; Department of Neurology (A.M.K.), Wayne State University, Detroit Medical Center, MI; Stroke Clinic (V.C.-N, A.A.), Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico; Department of Neurology (P.A.), Fundación Valle del Lili, Cali, Colombia; Centro de Investigaciones Clínicas (N.L., A.A.), Fundación Valle del Lili, Cali, Colombia; Department of Neurology (M.A.V.), Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Péru; Hospital General San Juan de Dios (J.D.B.G.), Guatemala; Department of Neurology (R.C., R.T.M.), Hospital Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil; Ramos Mejía Hospital (S.D.S.), Stroke Unit, Buenos Aires, Argentina; St. Luke's Medical Center (P.M.Y.), Global City, Philippines; Department of Neurology (S.N., A.G.), Grant Medical College and Sir JJ Hospital, Mumbai, India; Department of Neurology (K.-D.S.), National Health Insurance Service Ilsan Hospital, Goyang, Korea; School of Biomedical Engineering and Imaging Sciences (G.G.), St Thomas Hospital, King's College London, UK; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece.
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Theo Brehm T, Flottmann F, Dührsen L. Brain Abscess Due to Streptococcus Anginosus After Professional Dental Cleaning. Dtsch Arztebl Int 2023; 120:13. [PMID: 37982883 PMCID: PMC10035341 DOI: 10.3238/arztebl.m2022.0262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Thomas Theo Brehm
- *Sektion Infektiologie, I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf,
| | - Fabian Flottmann
- **Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf
| | - Lasse Dührsen
- ***Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf
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Broocks G, McDonough R, Bechstein M, Hanning U, Brekenfeld C, Flottmann F, Kniep H, Nawka MT, Deb-Chatterji M, Thomalla G, Sporns P, Yeo LL, Tan BY, Gopinathan A, Kastrup A, Politi M, Papanagiotou P, Kemmling A, Fiehler J, Meyer L. Benefit and risk of intravenous alteplase in patients with acute large vessel occlusion stroke and low ASPECTS. J Neurointerv Surg 2023; 15:8-13. [PMID: 35078927 DOI: 10.1136/neurintsurg-2021-017986] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [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: 07/06/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The benefit of best medical treatment including intravenous alteplase (IVT) before mechanical thrombectomy (MT) in patients with acute ischemic stroke and extensive early ischemic changes on baseline CT remains uncertain. The purpose of this study was to evaluate the benefit of IVT for patients with low ASPECTS (Alberta Stroke Programme Early CT Score) compared with patients with or without MT. METHODS This multicenter study pooled consecutive patients with anterior circulation acute stroke and ASPECTS≤5 to analyze the impact of IVT on functional outcome, and to compare bridging IVT with direct MT. Functional endpoints were the rates of good (modified Rankin Scale (mRS) score ≤2) and very poor (mRS ≥5) outcome at day 90. Safety endpoint was the occurrence of symptomatic intracranial hemorrhage (sICH). RESULTS 429 patients were included. 290 (68%) received IVT and 168 (39%) underwent MT. The rate of good functional outcome was 14.4% (95% CI 7.1% to 21.8%) for patients who received bridging IVT and 24.4% (95% CI 16.5% to 32.2%) for those who underwent direct MT. The rate of sICH was significantly higher in patients with bridging IVT compared with direct MT (17.8% vs 6.4%, p=0.004). In multivariable logistic regression analysis, IVT was significantly associated with very poor outcome (OR 2.22, 95% CI 1.05 to 4.73, p=0.04) and sICH (OR 3.44, 95% CI 1.18 to 10.07, p=0.02). Successful recanalization, age, and ASPECTS were associated with good functional outcome. CONCLUSIONS Bridging IVT in patients with low ASPECTS was associated with very poor functional outcome and an increased risk of sICH. The benefit of this treatment should therefore be carefully weighed in such scenarios. Further randomized controlled trials are required to validate our findings.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Leonard Ll Yeo
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Yq Tan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anil Gopinathan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Maria Politi
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany.,National and Kapodistrian University of Athens, Aretaiio Hospital, Athens, Greece
| | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Quandt F, Meißner N, Wölfer TA, Flottmann F, Deb-Chatterji M, Kellert L, Fiehler J, Goyal M, Saver JL, Gerloff C, Thomalla G, Tiedt S. RCT versus real-world cohorts: Differences in patient characteristics drive associations with outcome after EVT. Eur Stroke J 2022; 8:231-240. [PMID: 37021166 PMCID: PMC10069173 DOI: 10.1177/23969873221142642] [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] [Received: 07/25/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
Background: The selection of patients with large-vessel occlusion (LVO) stroke for endovascular treatment (EVT) depends on patient characteristics and procedural metrics. The relation of these variables to functional outcome after EVT has been assessed in numerous datasets from both randomized controlled trials (RCT) and real-world registries, but whether differences in their case mix modulate outcome prediction is unknown. Methods: We leveraged data from individual patients with anterior LVO stroke treated with EVT from completed RCTs from the Virtual International Stroke Trials Archive ( N = 479) and from the German Stroke Registry ( N = 4079). Cohorts were compared regarding (i) patient characteristics and procedural pre-EVT metrics, (ii) these variables’ relation to functional outcome, and (iii) the performance of derived outcome prediction models. Relation to outcome (functional dependence defined by a modified Rankin Scale score of 3–6 at 90 days) was analyzed by logistic regression models and a machine learning algorithm. Results: Ten out of 11 analyzed baseline variables differed between the RCT and real-world cohort: RCT patients were younger, had higher admission NIHSS scores, and received thrombolysis more often (all p < 0.0001). Largest differences at the level of individual outcome predictors were observed for age (RCT: adjusted odds ratio (aOR), 1.29 (95% CI, 1.10–1.53) vs real-world aOR, 1.65 (95% CI, 1.54–1.78) per 10-year increments, p < 0.001). Treatment with intravenous thrombolysis was not significantly associated with functional outcome in the RCT cohort (aOR, 1.64 (95 % CI, 0.91–3.00)), but in the real-world cohort (aOR, 0.81 (95% CI, 0.69–0.96); p for cohort heterogeneity = 0.056). Outcome prediction was more accurate when constructing and testing the model using real-world data compared to construction with RCT data and testing on real-world data (area under the curve, 0.82 (95% CI, 0.79–0.85) vs 0.79 (95% CI, 0.77–0.80), p = 0.004). Conclusions: RCT and real-world cohorts considerably differ in patient characteristics, individual outcome predictor strength, and overall outcome prediction model performance.
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Affiliation(s)
- Fanny Quandt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nina Meißner
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Teresa A Wölfer
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
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Deb-Chatterji M, Flottmann F, Meyer L, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G, Fiehler J, Thomalla G, Alegiani A, Boeckh-Behrens, Wunderlich S, Ernemann U, Poli S, Siebert E, Nolte CH, Zweynert S, Bohner G, Ludolph A, Henn KH, Schäfer JH, Keil F, Röther J, Eckert B, Berrouschot J, Bormann A, Dorn F, Petzold G, Kraemer C, Leischner H, Trumm C, Tiedt S, Kellert L, Petersen M, Stögbauer F, Braun M, Hamann GF, Gröschel K, Uphaus T, Reich A, Nikoubashman O, Schellinger P, Borggrefe J, Hattingen J, Liman J, Ernst M. Side matters: differences in functional outcome and quality of life after thrombectomy in left and right hemispheric stroke. Neurol Res Pract 2022; 4:58. [PMID: 36411484 PMCID: PMC9677692 DOI: 10.1186/s42466-022-00223-7] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/12/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients with a left (LHS) or right hemispheric stroke (RHS) differ in terms of clinical symptoms due to lateralization of specific cortical functions. Studies on functional outcome after stroke and endovascular thrombectomy (EVT) comparing both hemispheres showed conflicting results so far. The impact of stroke laterality on patient-reported health-related quality of life (HRQoL) after EVT has not yet been adequately addressed and still remains unclear. METHODS Consecutive stroke thrombectomy patients, derived from a multi-center, prospective registry (German Stroke Registry) between June 2015 and December 2019, were included in this study. At 90 days, outcome after EVT was assessed by the modified Rankin scale (mRS) and HRQoL using the European QoL-five dimensions questionnaire utility-index (EQ-5D-I; higher values indicate better HRQoL) in patients with LHS and RHS. Adjusted regression analysis was applied to evaluate the influence of stroke laterality on outcome after EVT. RESULTS In total, 5683 patients were analyzed. Of these, 2953 patients (52.8%) had LHS and 2637 (47.2%) RHS. LHS patients had a higher baseline NIHSS (16 vs. 13, p < 0.001) and a higher ASPECTS (9 vs. 8, p < 0.001) compared to RHS patients. Among survivors, patients with LHS less frequently had a self-reported affected mobility (p = 0.037), suffered less often from pain (p = 0.04) and anxiety/depression (p = 0.032) three months after EVT. After adjusting for confounders (age, sex, baseline NIHSS), LHS was associated with a better HRQoL (ß coefficient 0.04, CI 95% 0.017-0.063; p = 0.001), and better functional outcome assessed by lower values on the mRS (ß coefficient - 0.109, CI 95% - 0.217-0.000; p = 0.049). CONCLUSIONS Ninety days after EVT, LHS patients have a better functional outcome and HRQoL. Patients with RHS should be actively assessed and treated for pain, anxiety and depression to improve their HRQoL after EVT.
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Affiliation(s)
- Milani Deb-Chatterji
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Fabian Flottmann
- grid.13648.380000 0001 2180 3484Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- grid.13648.380000 0001 2180 3484Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- grid.13648.380000 0001 2180 3484Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- grid.13648.380000 0001 2180 3484Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Götz Thomalla
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Winder AJ, Wilms M, Amador K, Flottmann F, Fiehler J, Forkert ND. Predicting the tissue outcome of acute ischemic stroke from acute 4D computed tomography perfusion imaging using temporal features and deep learning. Front Neurosci 2022; 16:1009654. [PMID: 36408399 PMCID: PMC9672821 DOI: 10.3389/fnins.2022.1009654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/12/2022] [Indexed: 12/27/2023] Open
Abstract
Predicting follow-up lesions from baseline CT perfusion (CTP) datasets in acute ischemic stroke patients is important for clinical decision making. Deep convolutional networks (DCNs) are assumed to be the current state-of-the-art for this task. However, many DCN classifiers have not been validated against the methods currently used in research (random decision forests, RDF) and clinical routine (Tmax thresholding). Specialized DCNs have even been designed to extract complex temporal features directly from spatiotemporal CTP data instead of using standard perfusion parameter maps. However, the benefits of applying deep learning to source or deconvolved CTP data compared to perfusion parameter maps have not been formally investigated so far. In this work, a modular UNet-based DCN is proposed that separates temporal feature extraction from tissue outcome prediction, allowing for both model validation using perfusion parameter maps as well as end-to-end learning from spatiotemporal CTP data. 145 retrospective datasets comprising baseline CTP imaging, perfusion parameter maps, and follow-up non-contrast CT with manual lesion segmentations were assembled from acute ischemic stroke patients treated with intravenous thrombolysis alone (IV; n = 43) or intra-arterial mechanical thrombectomy (IA; n = 102) with or without combined IV. Using the perfusion parameter maps as input, the proposed DCN (mean Dice: 0.287) outperformed the RDF (0.262) and simple Tmax-thresholding (0.249). The performance of the proposed DCN was approximately equal using features optimized from the deconvolved residual curves (0.286) compared to perfusion parameter maps (0.287), while using features optimized from the source concentration-time curves (0.296) provided the best tissue outcome predictions.
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Affiliation(s)
- Anthony J. Winder
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Matthias Wilms
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Kimberly Amador
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D. Forkert
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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Broocks G, Hanning U, Bechstein M, Elsayed S, Faizy TD, Brekenfeld C, Flottmann F, Kniep H, Deb-Chatterji M, Schön G, Thomalla G, Kemmling A, Fiehler J, Meyer L. Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction. JAMA Netw Open 2022; 5:e2235733. [PMID: 36239941 PMCID: PMC9568804 DOI: 10.1001/jamanetworkopen.2022.35733] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Only limited data are available about a potential benefit associated with endovascular treatment (EVT) for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. OBJECTIVE To assess the association of recanalization after EVT with functional outcomes for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included patients enrolled in the German Stroke Registry-Endovascular Treatment with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less who presented between 6 and 24 hours after stroke onset and underwent computed tomography and subsequent EVT between July 1, 2015, and December 31, 2019. MAIN OUTCOMES AND MEASURES The primary end point was a modified Rankin Scale (mRS) score of 3 or less at day 90. The association between recanalization (defined as the occurrence of a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3) and outcome was assessed using logistic regression and inverse probability weighting analysis. INTERVENTION Endovascular treatment. RESULTS Of 5853 patients, 285 (5%; 146 men [51%]; median age, 73 years [IQR, 62-81 years]) met the inclusion criteria and were analyzed. Of these 285 patients, 79 (27.7%) had an mRS score of 3 or less at day 90. The rate of successful recanalization was 75% (215 of 285) and was independently associated with a higher probability of reaching an mRS score of 3 or less (adjusted odds ratio, 4.39; 95% CI, 1.79-10.72; P < .001). In inverse probability weighting analysis, a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3 was associated with a 19% increase (95% CI, 9%-29%; P < .001) in the probability for an mRS score of 3 or more. Multivariable logistic regression analysis suggested a significant treatment benefit associated with vessel recanalization in a time window of up to 17.6 hours and ASPECTS of 3 to 5. The rate of secondary symptomatic intracerebral hemorrhage was 6.3% (18 of 285). CONCLUSIONS AND RELEVANCE In this cohort study reflecting daily clinical practice, vessel recanalization for patients with a low ASPECTS and extended time window was associated with better functional outcomes in a time window up to 17.6 hours and ASPECTS of 3 to 5. The results of this study encourage current randomized clinical trials to enroll patients with a low ASPECTS, even within the extended time window.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Steffen P, Van Horn N, McDonough R, Deb-Chatterji M, Alegiani AC, Thomalla G, Fiehler J, Flottmann F. Continuing early mTICI 2b recanalization may improve functional outcome but is associated with a higher risk of intracranial hemorrhage. Front Neurol 2022; 13:955242. [PMID: 36226091 PMCID: PMC9549059 DOI: 10.3389/fneur.2022.955242] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSuccessful reperfusion (mTICI 2c/3) and low number of passes are key determinants for good clinical outcome in acute large vessel occlusion. While final mTICI 2c/3 reperfusion is superior to partial reperfusion (mTICI 2b) it remains unclear if this is also true for the subgroup of patients with early mTICI 2b (achieved in ≤2 retrieval attempts) reperfusion who are secondarily improved to mTICI 2c/3. This study was designed to examine if early mTICI2b should be continued or stopped during mechanical thrombectomy (MT).MethodsNine hundred and thirteen ischemic stroke patients who received MT were retrospectively analyzed. Angiography runs following each recanalization attempt were scored for mTICI. The patients with early mTICI 2b reperfusions were dichotomized in “TICI2b-stopped” (MT withdrawal after mTICI 2b was achieved with first or second retrieval) and “TICI2b-continued” (MT was continued after mTICI 2b was achieved with first or second retrieval). Functional outcome was obtained after 90 days using the modified Rankin scale (mRS90).ResultsOf 362 Patients with a M1-occlusion, 100 patients fulfilled the inclusion criteria with an early mTICI 2b. 78/100 patients were included in the “TICI2b-stopped” group and 22/100 patients were in the “TICI2b-continued” group. Of these 22 patients, none had a final mTICI score lower than 2b and 11 patients had a final mTICI score of 2c/3. Regarding good functional outcome at mRS90, “TICI2b-continued” showed by trend a slight advantage of 40.1 vs. 35.6% in “TICI2b-stopped” but in multivariate logistic regression analysis adjusted for confounders, no significant difference was found between the two groups (OR 0.75, 95% CI 0.19–2.87, p = 0.67). Symptomatic intracranial hemorrhage was significantly higher in “TICI2b-continued” compared to “TICI2b-stopped” (31.8 vs. 10.3%, p = 0.031).ConclusionSuccessfully improving an early mTICI 2b to mTICI 2c/3 reperfusion is possible in a substantial number of patients and might improve functional outcome. However, an increase in symptomatic intracranial hemorrhage (SICH) due to further retrieval attempts may diminish the potential functional benefit to continue early mTICI 2b. To support this finding, further investigation with more power is needed to account for the low number of events regarding SICH.
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Affiliation(s)
- Paul Steffen
- Department for Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Paul Steffen
| | - Noel Van Horn
- Department for Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Foothills Medical Centre, Alberta Health Services, Calgary, AB, Canada
| | - Milani Deb-Chatterji
- Department for Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Christina Alegiani
- Department for Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department for Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department for Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department for Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Guerreiro H, Wortmann N, Andersek T, Ngo TN, Frölich AM, Krause D, Fiehler J, Kyselyova AA, Flottmann F. Novel synthetic clot analogs for in-vitro stroke modelling. PLoS One 2022; 17:e0274211. [PMID: 36083986 PMCID: PMC9462564 DOI: 10.1371/journal.pone.0274211] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 08/19/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose
The increased demand for training of mechanical thrombectomy in ischemic stroke and development of new recanalization devices urges the creation of new simulation models both for training and device assessment. Clots properties have shown to play a role in procedural planning and thrombectomy device effectiveness. In this study, we analyzed the characteristics and applicability of completely synthetic, animal-free clots in the setting of an in-vitro model of mechanical thrombectomy for training and device assessment.
Methods
Synthetic clots based on agarose (n = 12) and silicone (n = 11) were evaluated in an in-vitro neurointervention simulation of mechanical thrombectomy with clot extraction devices. Calcified clots of mixed nature were simulated with addition of 3D printed structures. 9 clots were excluded due to insufficient vessel occlusion and failure to integrate with clot extraction device. Synthetic thrombi were characterized and compared using a categorical score-system on vessel occlusion, elasticity, fragmentation, adherence and device integration.
Results
Both agarose-based and silicone-based clots demonstrated relevant flow arrest and a good integration with the clot extraction device. Silicone-based clots scored higher on adherence to the vessel wall and elasticity.
Conclusion
Selected synthetic clots can successfully be implemented in an in-vitro training environment of mechanical thrombectomy. The clots’ different properties might serve to mimic fibrin-rich and red blood cell-rich human thrombi.
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Affiliation(s)
- Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Nadine Wortmann
- Institute of Product Development and Mechanical Engineering Design, Hamburg University of Technology, Hamburg, Germany
| | - Thomas Andersek
- Institute of Product Development and Mechanical Engineering Design, Hamburg University of Technology, Hamburg, Germany
| | - Tuan N. Ngo
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas M. Frölich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dieter Krause
- Institute of Product Development and Mechanical Engineering Design, Hamburg University of Technology, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna A. Kyselyova
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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31
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Styczen H, Maus V, Goertz L, Köhrmann M, Kleinschnitz C, Fischer S, Möhlenbruch M, Mühlen I, Kallmünzer B, Dorn F, Lakghomi A, Gawlitza M, Kaiser D, Klisch J, Lobsien D, Rohde S, Ellrichmann G, Behme D, Thormann M, Flottmann F, Winkelmeier L, Gizewski ER, Mayer-Suess L, Boeckh-Behrens T, Riederer I, Klingebiel R, Berger B, Schlunz-Hendann M, Grieb D, Khanafer A, du Mesnil de Rochemont R, Arendt C, Altenbernd J, Schlump JU, Ringelstein A, Sanio VJM, Loehr C, Dahlke AM, Brockmann C, Reder S, Sure U, Li Y, Mühl-Benninghaus R, Rodt T, Kallenberg K, Durutya A, Elsharkawy M, Stracke P, Schumann MG, Bock A, Nikoubashman O, Wiesmann M, Henkes H, Mosimann PJ, Chapot R, Forsting M, Deuschl C. Mechanical thrombectomy for acute ischemic stroke in COVID-19 patients: multicenter experience in 111 cases. J Neurointerv Surg 2022; 14:858-862. [PMID: 35292572 PMCID: PMC8931799 DOI: 10.1136/neurintsurg-2022-018723] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/02/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Data on the frequency and outcome of mechanical thrombectomy (MT) for large vessel occlusion (LVO) in patients with COVID-19 is limited. Addressing this subject, we report our multicenter experience. METHODS A retrospective cohort study was performed of consecutive acute stroke patients with COVID-19 infection treated with MT at 26 tertiary care centers between January 2020 and November 2021. Baseline demographics, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at discharge and 90 days were noted. RESULTS We identified 111 out of 11 365 (1%) patients with acute or subsided COVID-19 infection who underwent MT due to LVO. Cardioembolic events were the most common etiology for LVO (38.7%). Median baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score were 16 (IQR 11.5-20) and 9 (IQR 7-10), respectively. Successful reperfusion (mTICI ≥2b) was achieved in 97/111 (87.4%) patients and 46/111 (41.4%) patients were reperfused completely. The procedure-related complication rate was 12.6% (14/111). Functional independence was achieved in 20/108 (18.5%) patients at discharge and 14/66 (21.2%) at 90 days follow-up. The in-hospital mortality rate was 30.6% (33/108). In the subgroup analysis, patients with severe acute COVID-19 infection requiring intubation had a mortality rate twice as high as patients with mild or moderate acute COVID-19 infection. Acute respiratory failure requiring ventilation and time interval from symptom onset to groin puncture were independent predictors for an unfavorable outcome in a logistic regression analysis. CONCLUSION Our study showed a poor clinical outcome and high mortality, especially in patients with severe acute COVID-19 infection undergoing MT due to LVO.
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Affiliation(s)
- Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Langendreer, Bochum, Germany
| | - Lukas Goertz
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neurosciences and Behavioral Sciences (CTNBS), University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neurosciences and Behavioral Sciences (CTNBS), University Hospital Essen, Essen, Germany
| | - Sebastian Fischer
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Langendreer, Bochum, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Iris Mühlen
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Asadeh Lakghomi
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Gawlitza
- Institute and Policlinic of Neuroradiology, Universitatsklinikum Carl Gustav Carus, Dresden, Sachsen, Germany
| | - Daniel Kaiser
- Institute and Policlinic of Neuroradiology, Universitatsklinikum Carl Gustav Carus, Dresden, Sachsen, Germany
| | - Joachim Klisch
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Helios General Hospital Erfurt, Erfurt, Germany
| | - Donald Lobsien
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Helios General Hospital Erfurt, Erfurt, Germany
| | - Stefan Rohde
- Department of Radiology and Neuroradiology, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Gisa Ellrichmann
- Department of Neurology, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | | | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Mayer-Suess
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Isabelle Riederer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Randolf Klingebiel
- Department of Diagnostic and Interventional Neuroradiology, University Hospital OWL (Campus Bethel), Bielefeld, Germany
| | - Björn Berger
- Department of Diagnostic and Interventional Neuroradiology, University Hospital OWL (Campus Bethel), Bielefeld, Germany
| | - Martin Schlunz-Hendann
- Department of Radiology and Neuroradiology, Klinikum Duisburg - Sana Kliniken, Duisburg, Germany
| | - Dominik Grieb
- Department of Radiology and Neuroradiology, Klinikum Duisburg - Sana Kliniken, Duisburg, Germany
| | - Ali Khanafer
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Christophe Arendt
- Institute of Neuroradiology, University Hospital Frankfurt and Goethe University, Frankfurt am Main, Germany
| | - Jens Altenbernd
- Department of Radiology and Neuroradiology, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
| | - Jan-Ulrich Schlump
- Department of Neuropediatrics, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
| | - Adrian Ringelstein
- Department of Radiology and Neuroradiology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | | | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Agnes Maria Dahlke
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | - Sebastian Reder
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Yan Li
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - Thomas Rodt
- Department of Radiology, Klinikum Lueneburg, Lueneburg, Germany
| | - Kai Kallenberg
- Department of Neuroradiology, Klinikum Fulda, Fulda, Germany
| | | | | | - Paul Stracke
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | | | - Alexander Bock
- Department of Neuroradiology, Vivantes Klinikum Neukoelln, Berlin, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Hans Henkes
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Pascal J Mosimann
- Department of Neuroradiology, Alfried Krupp Hospital Ruttenscheid, Essen, Germany
| | - René Chapot
- Department of Neuroradiology, Alfried Krupp Hospital Ruttenscheid, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
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Kniep H, Bechstein M, Broocks G, Brekenfeld C, Flottmann F, van Horn N, Geest V, Faizy TD, Deb‐Chatterji M, Alegiani A, Thomalla G, Gellißen S, Fiehler J, Hanning U, Meyer L. Early Surrogates of Outcome after Thrombectomy in Posterior Circulation Stroke. Eur J Neurol 2022; 29:3296-3306. [DOI: 10.1111/ene.15519] [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] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | | | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
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Broocks G, Haupt W, McDonough R, Elsayed S, Flottmann F, Bechstein M, Schön G, Kniep H, Kemmling A, Zeleňák K, Fiehler J, Hanning U, Meyer L. Impact of relative cerebral blood volume reduction on early neurological improvement in extensive ischemic stroke. Eur J Neurol 2022; 29:3264-3272. [PMID: 35808904 DOI: 10.1111/ene.15491] [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] [Received: 06/08/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The benefit of endovascular treatment (EVT) for patients with low ASPECTS is yet ambiguous and currently investigated in randomized trials. As a tool for estimation of infarct extent and progression, CT-perfusion might predict early neurological improvement (ENI) after EVT. OBJECTIVE We hypothesized that the degree of relative cerebral blood volume (rCBV) reduction is directly associated with ENI in low ASPECTS patients undergoing EVT. METHODS Ischemic stroke patients with ASPECTS≤5 who received multimodal-CT and underwent thrombectomy were analyzed. The rCBV reduction was defined as the ratio of CBV measured in the ischemic lesion and contralateral CBV. Complete reperfusion was defined as eTICI 2c-3. Clinical endpoint was early neurological improvement (ENI) at 24-hours defined continuously (NIHSS change from baseline to 24-hours) and binarized (NIHSS at 24-hours≤8). RESULTS 102 patients were included. Lower rCBV reduction and complete EVT were independently associated with ENI (-11.4 NIHSS points, p=0.04; -7.3 points, p<0.0001, respectively). The effect of complete EVT on ENI was directly linked to the degree of rCBV reduction: the probability for binary ENI was +34.6%, p=0.004 in patients with low rCBV reduction versus +8.2%, p=0.28 in patients with high rCBV reduction. CONCLUSION In ischemic stroke with low ASPECTS, ENI was directly linked to the degree of rCBV reduction as a potential indicator of ischemia depth in extensive baseline infarction. Lower rCBV reduction was associated with higher probability of ENI after complete reperfusion suggesting a less pronounced lesion progression despite its large extent and hence, a higher susceptibility to EVT.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Wolfgang Haupt
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Gerhard Schön
- Department of Neuroradiology, University Medical Center Marburg, Marburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Andre Kemmling
- Department of Neuroradiology, University Medical Center Marburg, Marburg, Germany
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
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Quandt F, Flottmann F, Madai VI, Alegiani A, Küpper C, Kellert L, Hilbert A, Frey D, Liebig T, Fiehler J, Goyal M, Saver JL, Gerloff C, Thomalla G, Tiedt S. Machine Learning-Based Identification of Target Groups for Thrombectomy in Acute Stroke. Transl Stroke Res 2022; 14:311-321. [PMID: 35670996 PMCID: PMC10159968 DOI: 10.1007/s12975-022-01040-5] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/19/2022] [Accepted: 05/22/2022] [Indexed: 11/29/2022]
Abstract
Whether endovascular thrombectomy (EVT) improves functional outcome in patients with large-vessel occlusion (LVO) stroke that do not comply with inclusion criteria of randomized controlled trials (RCTs) but that are considered for EVT in clinical practice is uncertain. We aimed to systematically identify patients with LVO stroke underrepresented in RCTs who might benefit from EVT. Following the premises that (i) patients without reperfusion after EVT represent a non-treated control group and (ii) the level of reperfusion affects outcome in patients with benefit from EVT but not in patients without treatment benefit, we systematically assessed the importance of reperfusion level on functional outcome prediction using machine learning in patients with LVO stroke treated with EVT in clinical practice (N = 5235, German-Stroke-Registry) and in patients treated with EVT or best medical management from RCTs (N = 1488, Virtual-International-Stroke-Trials-Archive). The importance of reperfusion level on outcome prediction in an RCT-like real-world cohort equaled the importance of EVT treatment allocation for outcome prediction in RCT data and was higher compared to an unselected real-world population. The importance of reperfusion level was magnified in patient groups underrepresented in RCTs, including patients with lower NIHSS scores (0-10), M2 occlusions, and lower ASPECTS (0-5 and 6-8). Reperfusion level was equally important in patients with vertebrobasilar as with anterior LVO stroke. The importance of reperfusion level for outcome prediction identifies patient target groups who likely benefit from EVT, including vertebrobasilar stroke patients and among patients underrepresented in RCT patients with low NIHSS scores, low ASPECTS, and M2 occlusions.
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Affiliation(s)
- Fanny Quandt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vince I Madai
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany.,QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,School of Computing and Digital Technology, Faculty of Computing, Engineering and the Built Environment, Birmingham City University, Birmingham, UK
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clemens Küpper
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Adam Hilbert
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dietmar Frey
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mayank Goyal
- Department of Radiology, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Feodor-Lynen-Straße 17, 81377, Munich, Germany.
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Faizy TD, Mlynash M, Kabiri R, Christensen S, Kuraitis GM, Mader MM, Flottmann F, Broocks G, Lansberg MG, Albers GW, Marks MP, Fiehler J, Wintermark M, Heit JJ. The Cerebral Collateral Cascade: Comprehensive Blood Flow in Ischemic Stroke. Neurology 2022; 98:e2296-e2306. [PMID: 35483902 DOI: 10.1212/wnl.0000000000200340] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/21/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Robust cerebral collaterals are associated with favorable outcomes in patients with acute ischemic stroke due to large vessel occlusion treated by thrombectomy. However, collateral status assessment mostly relies on single imaging biomarkers and a more comprehensive holistic approach may provide deeper insights into the biology of collateral perfusion on medical imaging. Comprehensive collateralization is defined as blood flow of cerebral arteries through the brain tissue and into draining veins. We hypothesized that a comprehensive analysis of the cerebral collateral cascade (CCC) on an arterial, tissue, and venous level would predict clinical and radiologic outcomes. METHODS This was a multicenter retrospective cohort study of patients with acute stroke undergoing thrombectomy triage. CCC was determined by quantifying pial arterial collaterals, tissue-level collaterals, and venous outflow (VO). Pial arterial collaterals were determined by CT angiography; tissue-level collaterals were assessed on CT perfusion. VO was assessed on CT angiography using the cortical vein opacification score. Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and VO), CCC- (poor pial collaterals, tissue-level collaterals, and VO), and CCCmixed (the remainder of the patients). Primary outcome was functional independence (modified Rankin Scale score 0-2) at 90 days. Secondary outcome was final infarct volume. RESULTS A total of 647 patients met inclusion criteria: 176 CCC+, 345 CCCmixed, and 126 CCC-. Multivariable ordinal logistic regression showed that CCC+ predicted good functional outcomes (odds ratio [OR] 18.9 [95% CI 8-44.5]; p < 0.001) compared with CCC- and CCCmixed. CCCmixed patients likely had better functional outcomes compared with CCC- patients (OR 2.5 [95% CI 1.2-5.4]; p = 0.014). Quantile regression analysis (50th percentile) showed that CCC+ (β -78.5, 95% CI -96.0 to -61.1; p < 0.001) and CCCmixed (β -64.0, 95% CI -82.4 to -45.6; p < 0.001) profiles were associated with considerably lower final infarct volumes compared with CCC- profiles. DISCUSSION Comprehensive assessment of the collateral blood flow cascade in patients with acute stroke is a strong predictor of clinical and radiologic outcomes in patients treated by thrombectomy.
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Affiliation(s)
- Tobias Djamsched Faizy
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Michael Mlynash
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Reza Kabiri
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Soren Christensen
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriella Marie Kuraitis
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Marius M Mader
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Fabian Flottmann
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Maarten G Lansberg
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gregory W Albers
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Michael P Marks
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Max Wintermark
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jeremy J Heit
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany.
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Kniep H, Meyer L, Bechstein M, Broocks G, Guerreiro H, van Horn N, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Thomalla G, Hanning U, Fiehler J, Gellißen S. How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge? Stroke 2022; 53:2828-2837. [PMID: 35549377 DOI: 10.1161/strokeaha.121.037888] [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
BACKGROUND Early neurological status has been described as predictor of functional outcome in patients with anterior circulation stroke after mechanical thrombectomy. It remains unclear to what proportion the improvement of functional outcome at day 90 is already apparent at 24 hours and at hospital discharge and how later factors impact outcome. METHODS All patients enrolled in the German Stroke Registry (June 2015-December 2019) with anterior circulation stroke and availability of baseline data and neurological status were included. A mediation analysis was conducted to investigate the effect of successful recanalization (Thrombolysis in Cerebral Infarction scale score ≥2b) on good functional outcome (modified Rankin Scale score ≤2 at day 90) with mediation through neurological status (National Institutes of Health Stroke Scale [NIHSS] at 24 hours and at hospital discharge). RESULTS Three thousand fifty-seven patients fulfilled the inclusion criteria, thereof 2589 (85%) with successful recanalization and 1180 (39%) with good functional outcome. In a multivariate logistic regression analysis, probability of good outcome was significantly associated with age (odds ratio [95% CI], 0.95 [0.94-0.96]), prestroke modified Rankin Scale (0.48 [0.42-0.55]), admission-NIHSS (0.96 [0.94-0.98]), 24-hour NIHSS (0.83 [0.81-0.84]), diabetes (0.56 [0.43-0.72]), proximal middle cerebral artery occlusions (0.78 [0.62-0.97]), passes (0.88 [0.82-0.95]), Alberta Stroke Program Early CT Score (1.07 [1.00-1.14]), successful recanalization (2.39 [1.68-3.43]), intracerebral hemorrhage (0.51 [0.35-0.73]), and recurrent strokes (0.54 [0.32-0.92]). Mediation analysis showed a 20 percentage points (95% CI' 17-24 percentage points) increase of probability of good functional outcome after successful recanalization. Fifty-four percent (95% CI' 44%-66%) of the improvement in functional outcome was explained by 24-hour NIHSS and 75% (95% CI' 62%-90%) by NIHSS at hospital discharge. CONCLUSIONS Fifty-four percent of the improvement in functional outcome after successful recanalization is apparent in NIHSS at 24 hours, 75% in NIHSS at hospital discharge. Other unknown factors not apparent in NIHSS at the 2 time points investigated account for the remaining effect on long term outcome, suggesting, among others, clinical relevance of delayed neurological improvement and deterioration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03356392.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., A.A., G.T.)
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany (A.A)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., A.A., G.T.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
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Deb-Chatterji M, Pinho J, Flottmann F, Meyer L, Broocks G, Brekenfeld C, Reich A, Fiehler J, Gerloff C, Thomalla G. Health-related quality of life after thrombectomy in young-onset versus older stroke patients: a multicenter analysis. J Neurointerv Surg 2021; 14:1145-1150. [PMID: 34876497 DOI: 10.1136/neurintsurg-2021-017991] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/06/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Information is lacking on self-reported health-related quality of life (HRQoL) as a complementary outcome measure in addition to the modified Rankin scale (mRS) in young patients with ischemic stroke after endovascular thrombectomy (EVT) compared with older patients. METHODS Data on consecutive patients with stroke who underwent thrombectomy (June 2015-2019) from a multicenter prospective registry (German Stroke Registry) were analyzed. HRQoL was measured by the European QoL-5 dimension questionnaire utility index (EQ-5D-I; higher values indicate better HRQoL) 3 months after stroke in patients aged ≤55 and >55 years. Multivariate regression analyses identified predictors of better HRQoL. RESULTS Of 4561 included patients, 526 (11.5%) were ≤55 years old. Young-onset patients had a better outcome assessed by mRS (mRS 0-2: 64.3% vs 31.8%, p<0.001) and EQ-5D-I (mean 0.639 vs 0.342, p<0.001). Young survivors after EVT had fewer complaints in the EQ-5D domains mobility (p<0.001), self-care (p<0.001), usual activities (p<0.001) and pain/discomfort (p=0.008), whereas no difference was observed in anxiety/depression (p=0.819). Adjusted regression analysis for 90-day mRS showed no difference in HRQoL between the two subgroups of patients. Lower age, National Institutes of Health Stroke Scale score and pre-stroke mRS, a higher Alberta Stroke Program Early CT Score, concomitant intravenous thrombolysis therapy and successful recanalization were associated with better HRQoL in both patient subgroups. CONCLUSIONS Young-onset stroke patients have a better HRQoL after EVT than older patients. Their higher HRQoL is mainly explained by less physical disability assessed by mRS. Depressive symptoms should be actively assessed and targeted in rehabilitation therapies of young-onset stroke patients to improve quality of life after stroke.
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Affiliation(s)
- Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - João Pinho
- Department of Neurology, RWTH Aachen University, Aachen, Nordrhein-Westfalen, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arno Reich
- Department of Neurology, RWTH Aachen University, Aachen, Nordrhein-Westfalen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Leischner H, Brekenfeld C, Meyer L, Broocks G, Faizy T, McDonough R, Gerloff C, Thomalla G, Deb-Chatterji M, Fiehler J, Flottmann F. Study Criteria Applied to Real Life-A Multicenter Analysis of Stroke Patients Undergoing Endovascular Treatment in Clinical Practice. J Am Heart Assoc 2021; 10:e017919. [PMID: 34779226 PMCID: PMC8751914 DOI: 10.1161/jaha.120.017919] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Randomized controlled clinical trials (RCT) have demonstrated the efficacy of endovascular treatment in anterior circulation large vessel occlusions. However, outcome of patients treated in daily practice differs from the results of the clinical trials. We hypothesize that this is attributable to the study criteria and that application of the criteria on patients undergoing endovascular therapy in daily routine would improve their outcome. Methods and Results Data from a multicenter prospective registry of GSR‐ET (German Stroke Registry – Endovascular Treatment) was used. Inclusion criteria and selectivity of SWIFT‐PRIME (Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment trial), MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands trial), ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times trial), DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake‐Up and Late Presenting Strokes Undergoing Neurointervention with Trevo trial) and DEFUSE‐3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke trial) trials were analyzed. Baseline characteristics, procedural and outcome data of patients from GSR‐ET before and after selection were compared with the results of the RCTs. Furthermore, outcome of patients who underwent endovascular treatment despite not fulfilling the RCT criteria was analyzed. A total of 2611 patients were included (median age, 75 years; 49.6% women; median National Institute of Health Stroke Scale, 16). A minority of patients met all inclusion criteria, ranging from 3% (DEFUSE‐3 criteria) to 35% (MR CLEAN criteria). Of the patients fulfilling the MR CLEAN criteria, 41% of patients had a good clinical outcome, compared with 34% of patients that did not fulfill MR CLEAN criteria. Conclusions The RCTs represent a selected population with higher rates of good clinical outcome compared with daily practice. The good outcomes of RCTs can be reproduced in clinical routine in patients who fulfill the RCT inclusion criteria. Furthermore, patients who did not meet the criteria of the RCT still had substantial rates of good clinical outcome.
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Affiliation(s)
- Hannes Leischner
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Caspar Brekenfeld
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Lukas Meyer
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Gabriel Broocks
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Tobias Faizy
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Rosalie McDonough
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Christian Gerloff
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Milani Deb-Chatterji
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jens Fiehler
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Fabian Flottmann
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
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Broocks G, Faizy TD, Meyer L, Groffmann M, Elsayed S, Kniep H, Flottmann F, Bechstein M, Rusche T, Schön G, Nawabi J, Sporns P, Fiehler J, Kemmling A, Hanning U. Posterior circulation collateral flow modifies the effect of thrombectomy on outcome in acute basilar artery occlusion. Int J Stroke 2021; 17:761-769. [PMID: 34569885 DOI: 10.1177/17474930211052262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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 In basilar artery occlusion stroke, the impact of the collateral circulation on infarct progression in the context of endovascular treatment is yet poorly studied. AIM This study investigates the impact of the posterior circulation collateral score (PCCS) on functional outcome according to the extent of early ischemic changes and treatment. We hypothesized that the presence of collaterals, quantified by the PCCS, mediates the effect of endovascular treatment on functional outcome in patients with acute basilar artery occlusion. METHODS In this multicenter observational study, patients with basilar artery occlusion and admission computed tomography were analyzed. At baseline, Posterior circulation Acute Stroke Prognosis Early Computed Tomography score (pcASPECTS) was assessed and PCCS was quantified using an established 10-point grading system. Logistic regression analyses were performed to identify factors associated with good functional outcome (modified Rankin Scale scores 0-2 at day 90). RESULTS A total of 151 patients were included, of which 112 patients (74%) underwent endovascular treatment. In patients with a better PCCS (>5), the rate of good outcome was significantly higher (55% vs. 11%; p = 0.001). After adjusting for PCCS, vessel recanalization was significantly associated with improved functional outcome (aOR: 4.53, 95%CI: 1.25-16.4, p = 0.02), while there was no association between recanalization status and outcome in univariable analysis. Patients with low pcASPECTS generally showed very poor outcomes (mean modified Rankin Scale score 5.3, 95%CI: 4.9-5.8). CONCLUSION PCCS modified the effect of recanalization on functional outcome, particularly in patients with less pronounced ischemic changes in admission computed tomography. These results should be validated to improve patient selection for endovascular treatment in basilar artery occlusion, particularly in uncertain indications, or to triage patients at risk for very poor outcomes.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Groffmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thilo Rusche
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland.,Department of Clinical Radiology, University of Münster, Münster, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité University Medical Center, Berlin, Germany
| | - Peter Sporns
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, 9377University of Marburg, Marburg, Germany.,Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Nielsen M, Waldmann M, Frölich AM, Flottmann F, Hristova E, Bendszus M, Seker F, Fiehler J, Sentker T, Werner R. Deep Learning-Based Automated Thrombolysis in Cerebral Infarction Scoring: A Timely Proof-of-Principle Study. Stroke 2021; 52:3497-3504. [PMID: 34496622 DOI: 10.1161/strokeaha.120.033807] [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] [Indexed: 01/01/2023]
Abstract
Background and Purpose Mechanical thrombectomy is an established procedure for treatment of acute ischemic stroke. Mechanical thrombectomy success is commonly assessed by the Thrombolysis in Cerebral Infarction (TICI) score, assigned by visual inspection of X-ray digital subtraction angiography data. However, expert-based TICI scoring is highly observer-dependent. This represents a major obstacle for mechanical thrombectomy outcome comparison in, for instance, multicentric clinical studies. Focusing on occlusions of the M1 segment of the middle cerebral artery, the present study aimed to develop a deep learning (DL) solution to automated and, therefore, objective TICI scoring, to evaluate the agreement of DL- and expert-based scoring, and to compare corresponding numbers to published scoring variability of clinical experts. Methods The study comprises 2 independent datasets. For DL system training and initial evaluation, an in-house dataset of 491 digital subtraction angiography series and modified TICI scores of 236 patients with M1 occlusions was collected. To test the model generalization capability, an independent external dataset with 95 digital subtraction angiography series was analyzed. Characteristics of the DL system were modeling TICI scoring as ordinal regression, explicit consideration of the temporal image information, integration of physiological knowledge, and modeling of inherent TICI scoring uncertainties. Results For the in-house dataset, the DL system yields Cohen’s kappa, overall accuracy, and specific agreement values of 0.61, 71%, and 63% to 84%, respectively, compared with the gold standard: the expert rating. Values slightly drop to 0.52/64%/43% to 87% when the model is, without changes, applied to the external dataset. After model updating, they increase to 0.65/74%/60% to 90%. Literature Cohen’s kappa values for expert-based TICI scoring agreement are in the order of 0.6. Conclusions The agreement of DL- and expert-based modified TICI scores in the range of published interobserver variability of clinical experts highlights the potential of the proposed DL solution to automated TICI scoring.
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Affiliation(s)
- Maximilian Nielsen
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Moritz Waldmann
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Andreas M Frölich
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | | | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Germany (M.B., F.S.)
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Germany (M.B., F.S.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Thilo Sentker
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Rene Werner
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
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Meyer L, Bechstein M, Bester M, Hanning U, Brekenfeld C, Flottmann F, Kniep H, van Horn N, Deb-Chatterji M, Thomalla G, Sporns P, Yeo LLL, Tan BYQ, Gopinathan A, Kastrup A, Politi M, Papanagiotou P, Kemmling A, Fiehler J, Broocks G. Thrombectomy in Extensive Stroke May Not Be Beneficial and Is Associated With Increased Risk for Hemorrhage. Stroke 2021; 52:3109-3117. [PMID: 34470489 DOI: 10.1161/strokeaha.120.033101] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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 This study evaluates the benefit of endovascular treatment (EVT) for patients with extensive baseline stroke compared with best medical treatment. Methods This retrospective, multicenter study compares EVT and best medical treatment for computed tomography (CT)–based selection of patients with extensive baseline infarcts (Alberta Stroke Program Early CT Score ≤5) attributed to anterior circulation stroke. Patients were selected from the German Stroke Registry and 3 tertiary stroke centers. Primary functional end points were rates of good (modified Rankin Scale score of ≤3) and very poor outcome (modified Rankin Scale score of ≥5) at 90 days. Secondary safety end point was the occurrence of symptomatic intracerebral hemorrhage. Angiographic outcome was evaluated with the modified Thrombolysis in Cerebral Infarction Scale. Results After 1:1 pair matching, a total of 248 patients were compared by treatment arm. Good functional outcome was observed in 27.4% in the EVT group, and in 25% in the best medical treatment group (P=0.665). Advanced age (adjusted odds ratio, 1.08 [95% CI, 1.05–1.10], P<0.001) and symptomatic intracerebral hemorrhage (adjusted odds ratio, 6.35 [95% CI, 2.08–19.35], P<0.001) were independently associated with very poor outcome. Mortality (43.5% versus 28.9%, P=0.025) and symptomatic intracerebral hemorrhage (16.1% versus 5.6%, P=0.008) were significantly higher in the EVT group. The lowest rates of good functional outcome (≈15%) were observed in groups of failed and partial recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 0/1–2a), whereas patients with complete recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 3) with recanalization attempts ≤2 benefitted the most (modified Rankin Scale score of ≤3:42.3%, P=0.074) compared with best medical treatment. Conclusions In daily clinical practice, EVT for CT–based selected patients with low Alberta Stroke Program Early CT Score anterior circulation stroke may not be beneficial and is associated with increased risk for hemorrhage and mortality, especially in the elderly. However, first- or second-pass complete recanalization seems to reveal a clinical benefit of EVT highlighting the vulnerability of the low Alberta Stroke Program Early CT Score subgroup. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Switzerland (P.S.)
| | - Leonard Leong-Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T.).,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T., A.G.)
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T.).,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T., A.G.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore (A.G.).,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T., A.G.)
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany (A. Kastrup)
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Germany (M.P., P.P.)
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Germany (M.P., P.P.).,Areteion University Hospital, National and Kapodistrian University of Athens, Greece (P.P.)
| | - André Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany (A. Kemmling).,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Marburg, Marburg University, Germany (A. Kemmling)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Faizy TD, Kabiri R, Christensen S, Mlynash M, Kuraitis G, Broocks G, Flottmann F, Meyer L, Leischner H, Lansberg MG, Albers GW, Marks MP, Fiehler J, Wintermark M, Heit JJ. Distinct intra-arterial clot localization affects tissue-level collaterals and venous outflow profiles. Eur J Neurol 2021; 28:4109-4116. [PMID: 34424584 DOI: 10.1111/ene.15079] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 07/12/2021] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Arterial clot localization affects collateral flow to ischemic brain in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). We determined the association between vessel occlusion locations, tissue-level collaterals (TLC), and venous outflow (VO) profiles and their impact on good functional outcomes. METHODS We conducted a multicenter retrospective cohort study of consecutive AIS-LVO patients who underwent thrombectomy triage. Baseline computed tomographic angiography (CTA) was used to localize vessel occlusion, which was dichotomized into proximal vessel occlusion (PVO; internal carotid artery and proximal first segment of the middle cerebral artery [M1]) and distal vessel occlusion (DVO; distal M1 and M2), and to assess collateral scores. TLC were assessed on computed tomographic perfusion data using the hypoperfusion intensity ratio. VO was determined on baseline CTA by the cortical vein opacification score. Primary outcomes were favorable VO and TLC; secondary outcome was the modified Rankin Scale after 90 days. RESULTS A total of 649 patients met inclusion criteria. Of these, 376 patients (58%) had a PVO and 273 patients (42%) had a DVO. Multivariate ordinal logistic regression showed that DVO predicted favorable TLC (odds ratio [OR] = 1.77, 95% confidence interval [CI] = 1.24-2.52, p = 0.002) and favorable VO (OR = 7.2, 95% CI = 5.2-11.9, p < 0.001). DVO (OR = 3.4, 95% CI = 2.1-5.6, p < 0.001), favorable VO (OR = 6.4, 95% CI = 3.8-10.6, p < 0.001), and favorable TLC (OR = 3.2, 95% CI = 2-5.3, p < 0.001), but not CTA collaterals (OR = 1.07, 95% CI = 0.60-1.91, p = 0.813), were predictors of good functional outcome. CONCLUSIONS DVO in AIS-LVO patients correlates with favorable TLC and VO profiles, which are associated with good functional outcome.
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Affiliation(s)
- Tobias D Faizy
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA.,Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reza Kabiri
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Gabriella Kuraitis
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Michael P Marks
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
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43
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Nawabi J, Elsayed S, Scholz H, Kemmling A, Meyer L, Kniep H, Bechstein M, Flottmann F, Faizy TD, Schön G, Fiehler J, Hanning U, Broocks G. Interaction Effect of Baseline Serum Glucose and Early Ischemic Water Uptake on the Risk of Secondary Hemorrhage After Ischemic Stroke. Front Neurol 2021; 12:690193. [PMID: 34305796 PMCID: PMC8297562 DOI: 10.3389/fneur.2021.690193] [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: 04/02/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose: Intracerebral hemorrhage (ICH) after mechanical thrombectomy (MT) for acute ischemic stroke (AIS) remains a major complication and its early prediction is of high relevance. Baseline serum glucose (BGL) is a known predictor of ICH, but its interaction with early ischemic changes remains uncertain. We hypothesized that BGL interacts with the effect of tissue water uptake on the occurrence of ICH. Methods: Three hundred and thirty-six patients with acute ischemic stroke treated with MT were retrospectively analyzed. ICH was diagnosed within 24 h on non-enhanced CT (NECT) and classified according to the Heidelberg Bleeding Classification. Early tissue water homeostasis has been assessed using quantitative lesion net water uptake (NWU) on admission CT. Multivariate logistic regression was used to identify predictors of ICH. Results: One hundred and seven patients fulfilled the inclusion criteria of which 37 (34.6%) were diagnosed with ICH. Patients with ICH had a significant higher BGL on admission (median 177 mg/dl, IQR: 127-221.75, P < 0.001). In patients with low BGL (<120 mg/dl), higher NWU was associated with 1.34-fold increased likelihood of ICH, while higher NWU was associated with a 2.08-fold increased likelihood of ICH in patients with a high BGL (>200 mg/dl). In multivariable logistic regression analysis, BGL (OR: 1.02, 95% CI: 1.00-1.04, P = 0.01) and NWU (OR: 2.32, 95% CI: 1.44-3.73, P < 0.001) were significantly and independently associated with ICH, showing a significant interaction (P = 0.04). Conclusion: A higher degree of early tissue water uptake and high admission BGL were both independent predictors of ICH. Higher BGL was significantly associated with accelerated effects of NWU on the likelihood of ICH. Although a clear causal relationship remains speculative, stricter BGL control and monitoring may be tested to reduce the risk of ICH in patients undergoing thrombectomy.
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Affiliation(s)
- Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology (CCM), Charité - Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin, Germany
- Berlin Institute of Health, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henriette Scholz
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Kemmling
- University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
- University Medical Center Marburg, Marburg University, Marburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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44
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Broocks G, Elsayed S, Kniep H, Kemmling A, Flottmann F, Bechstein M, Faizy TD, Meyer L, Lindner T, Sporns P, Rusche T, Schön G, Mader MM, Nawabi J, Fiehler J, Hanning U. Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake. Neurosurgery 2021; 88:531-537. [PMID: 33040147 DOI: 10.1093/neuros/nyaa438] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malignant cerebellar edema (MCE) is a life-threatening complication of ischemic posterior circulation stroke that requires timely diagnosis and management. Yet, there is no established imaging biomarker that may serve as predictor of MCE. Early edematous water uptake can be determined using quantitative lesion water uptake, but this biomarker has only been applied in anterior circulation strokes. OBJECTIVE To test the hypothesis that lesion water uptake in early posterior circulation stroke predicts MCE. METHODS A total 179 patients with posterior circulation stroke and multimodal admission CT were included. A total of 35 (19.5%) patients developed MCE defined by using an established 10-point scale in follow-up CT, of which ≥4 points are considered malignant. Posterior circulation net water uptake (pcNWU) was quantified in admission CT based on CT densitometry and compared with posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) as predictor of MCE using receiver operating curve (ROC) analysis and logistic regression analysis. RESULTS Acute pcNWU within the early ischemic lesion was 24.6% (±8.4) for malignant and 7.2% (±7.4) for nonmalignant infarctions, respectively (P < .0001). Based on ROC analysis, pcNWU above 14.9% identified MCE with high discriminative power (area under the curve: 0.94; 95% CI: 0.89-0.97). Early pcNWU (odds ratio [OR]: 1.28; 95% CI: 1.15-1.42, P < .0001) and pc-ASPECTS (OR: 0.71, 95% CI: 0.53-0.95, P = .02) were associated with MCE, adjusted for age and recanalization status. CONCLUSION Quantitative pcNWU in early posterior circulation stroke is an important marker for MCE. Besides pc-ASPECTS, lesion water uptake measurements may further support identifying patients at risk for MCE at an early stage indicating stricter monitoring and consideration for further therapeutic measures.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University, Stanford, California
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Lindner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland
| | - Thilo Rusche
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland.,Department of Radiology, University Hospital Münster, Münster, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius M Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité University Medical Center, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Schlemm L, von Rennenberg R, Siebert E, Bohner G, Flottmann F, Petzold GC, Thomalla G, Endres M, Nolte CH. Mechanical thrombectomy in patients with cervical artery dissection and stroke in the anterior or posterior circulation - a multicenter analysis from the German Stroke Registry. Neurol Res Pract 2021; 3:20. [PMID: 33934710 PMCID: PMC8091690 DOI: 10.1186/s42466-021-00119-y] [Citation(s) in RCA: 3] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background Cervical artery dissection (CAD) is a rare cause of acute ischemic stroke (AIS) with large vessel occlusion (LVO) and may constitute a challenge for mechanical thrombectomy (MT). We compared procedural characteristics, reperfusion rates, and clinical outcome in AIS patients undergoing MT with and without CAD. Methods We performed a pre-specified analysis of patients registered within the German Stroke Registry, a prospectively maintained multicenter registry of consecutive patients with AIS patients treated by MT. Procedural characteristics included time periods and additional application of medication. Results Of 2589 patients, 62 (2.4%) were diagnosed with CAD. CAD patients were younger, had lower rates of known vascular risk factors and larger baseline stroke volumes. MT in CAD patients took significantly longer (median [IQR] groin-puncture-to-flow restoration time: 98 [67–136] versus 70 [45–100] minutes; p < 0.001) and more often required use of intra-arterial medication (34.4% versus 15.6%; p < 0.001). Reperfusion success (modified Treatment in Cerebral Infarction score 2b-3: 85.2% versus 83.3%, p = 0.690) and favorable functional outcome after 3 months (modified Rankin Scale score ≤ 2: 70.9% versus 36.4%, adjusted p = 0.086) did not differ significantly between patients with and without CAD. The latter findings held true for both CAD in the anterior and posterior circulation. Conclusion CAD in AIS requiring MT is rare. MT in patients with CAD constitutes a particular procedural challenge, but still achieves favorable radiological and functional outcomes in most patients. Our data provide indirect evidence that MT is of clinical benefit in patients with AIS due to LVO and CAD. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00119-y.
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Affiliation(s)
- Ludwig Schlemm
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany
| | - Regina von Rennenberg
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Berlin, Germany
| | - Eberhard Siebert
- Berlin Institute of Health (BIH), Berlin, Germany.,Department of Neuroradiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu, Berlin, Germany
| | - Georg Bohner
- Berlin Institute of Health (BIH), Berlin, Germany.,Department of Neuroradiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu, Berlin, Germany
| | - Fabian Flottmann
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Martinistr 52, 20246, Hamburg, Germany
| | - Gabor C Petzold
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Bonn, Germany.,Department of Neurology, Division of Vascular Neurology, University Hospital Bonn, Bonn, Germany
| | - Götz Thomalla
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Neurologie, Martinistr. 52, 20246, Hamburg, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany. .,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany. .,DZNE (German Center for Neurodegenerative Diseases), Partner Site Berlin, Berlin, Germany. .,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany. .,Department of Neurology, Charite - Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.
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Seker F, Fiehler J, Möhlenbruch MA, Herweh C, Flottmann F, Ringleb PA, Thomalla G, Steiner T, Kraemer C, Brekenfeld C, Bendszus M. Clinical Outcome After Endovascular Thrombectomy in 3 Triage Concepts: A Prospective, Observational Study (NEUROSQUAD). Stroke 2021; 52:e213-e216. [PMID: 33910365 DOI: 10.1161/strokeaha.120.030520] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE NEUROSQUAD (Stroke Treatment: Quality and Efficacy in Different Referral Systems) is a prospective, observational, bicenter study comparing 3 triage pathways in endovascular stroke treatment: mothership, drip and ship (DS), and transferring a neurointerventionalist to a remote hospital for thrombectomy (drive the doctor [DD]). METHODS Patients with anterior circulation stroke and premorbid modified Rankin Scale (mRS) score 0-3 who underwent thrombectomy within 24 hours after stroke onset were included. Primary outcome measure was good clinical outcome defined as 90-day mRS score 0-2 or clinical recovery to the status before stroke onset (ie, equal premorbid mRS and 90-day mRS). Secondary outcome measures were successful reperfusion, National Institutes of Health Stroke Scale at discharge, and mRS shift. RESULTS In total, 360 patients were included in this study, of whom 111 patients (30.8%) were in the mothership group, 204 patients (56.7%) were in the DS group, and 45 patients (12.5%) were in the DD group. Good clinical outcome was achieved similarly in all three groups (mothership, 45.9%; DS, 43.1%; DD, 40.0%; P=0.778). Likewise, frequency of successful reperfusion was similar in all three groups (mothership, 86.5%; DS, 85.3%; DD, 82.2%; P=0.714). There was no significant difference among the groups regarding the National Institutes of Health Stroke Scale at discharge (P=0.115) and mRS shift (P=0.342). In the multivariate analysis, triage concept was not an independent predictor of good outcome (unadjusted odds ratio, 0.89 [CI, 0.64-1.23]; P=0.479). CONCLUSIONS Our data suggest that clinical outcome after thrombectomy is similar in mothership, DS, and DD. Hence, DD can be a valuable triage option in acute stroke treatment.
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Affiliation(s)
- Fatih Seker
- Neuroradiology (F.S., M.A.M., C.H., M.B.), Heidelberg University Hospital, Germany
| | - Jens Fiehler
- Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Markus A Möhlenbruch
- Neuroradiology (F.S., M.A.M., C.H., M.B.), Heidelberg University Hospital, Germany
| | - Christian Herweh
- Neuroradiology (F.S., M.A.M., C.H., M.B.), Heidelberg University Hospital, Germany
| | - Fabian Flottmann
- Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Peter A Ringleb
- Neurology (P.A.R., T.S.), Heidelberg University Hospital, Germany
| | - Götz Thomalla
- Neurology (G.T.), University Hospital Hamburg-Eppendorf, Germany
| | - Thorsten Steiner
- Neurology (P.A.R., T.S.), Heidelberg University Hospital, Germany.,Neurology, Klinikum Frankfurt Höchst, Germany (T.S.)
| | | | - Caspar Brekenfeld
- Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Martin Bendszus
- Neuroradiology (F.S., M.A.M., C.H., M.B.), Heidelberg University Hospital, Germany
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Faizy TD, Kabiri R, Christensen S, Mlynash M, Kuraitis G, Meyer L, Marks MP, Broocks G, Flottmann F, Lansberg MG, Albers GW, Fiehler J, Wintermark M, Heit JJ. Venous Outflow Profiles Are Linked to Cerebral Edema Formation at Noncontrast Head CT after Treatment in Acute Ischemic Stroke Regardless of Collateral Vessel Status at CT Angiography. Radiology 2021; 299:682-690. [PMID: 33825511 DOI: 10.1148/radiol.2021203651] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Ischemic lesion net water uptake (NWU) at noncontrast head CT enables quantification of cerebral edema in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Purpose To assess whether favorable venous outflow (VO) profiles at CT angiography are associated with reduced NWU and good functional outcomes in patients with AIS due to LVO. Materials and Methods This multicenter retrospective cohort study evaluated consecutive patients with AIS due to LVO who underwent thrombectomy triage between January 2013 and December 2019. Arterial collateral vessel status (Tan scale) and venous output were measured at CT angiography. Venous outflow was graded with use of the cortical vein opacification score, which quantifies opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein. Favorable VO was regarded as a score of 3-6 and unfavorable VO as a score of 0-2. NWU was determined at follow-up noncontrast CT. Multivariable regression analyses were performed to determine the association between favorable VO profiles and NWU after treatment and good functional outcome (modified Rankin Scale, ≤2). Results A total of 580 patients were included. Of the 580 patients, 231 had favorable VO (104 women; median age, 73 years [interquartile range {IQR}, 62-81 years]) and 349 had unfavorable VO (190 women; median age, 77 years [IQR, 66-84 years]). Compared with patients with unfavorable VO, those with favorable VO exhibited lower baseline National Institutes of Health Stroke Scale score (median, 12.5 [IQR, 7-17] vs 17 [IQR, 13-21]), higher Alberta Stroke Program Early CT Score (median, 9 [IQR, 7-10] vs 7 [IQR, 6-8]), and less NWU after treatment (median, 7% [IQR, 4.6%-11.5%] vs 17.9% [IQR, 12.3%-22.2%]). In a multivariable regression analysis, NWU mean difference between patients with unfavorable VO and those with favorable VO was 6.1% (95% CI: 4.9, 7.3; P < .001) regardless of arterial CT angiography collateral vessel status (b coefficient, 0.72 [95% CI: -0.59, 2.03; P = .28]). Favorable VO (odds ratio [OR]: 4.1 [95% CI: 2.2, 7.7]; P < .001) and reduced NWU after treatment (OR: 0.77 [95% CI: 0.73, 0.83]; P < .001) were independently associated with good functional outcomes. Conclusion Favorable venous outflow (VO) correlated with reduced ischemic net water uptake (NWU) after treatment. Reduced NWU and favorable VO were associated with good functional outcomes regardless of CT angiography arterial collateral vessel status. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Tobias D Faizy
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Reza Kabiri
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Soren Christensen
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Michael Mlynash
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Gabriella Kuraitis
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Lukas Meyer
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Michael P Marks
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Gabriel Broocks
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Fabian Flottmann
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Maarten G Lansberg
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Gregory W Albers
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Jens Fiehler
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Max Wintermark
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Jeremy J Heit
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
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Maros ME, Brekenfeld C, Broocks G, Leischner H, McDonough R, Deb-Chatterji M, Alegiani A, Thomalla G, Fiehler J, Flottmann F. Number of Retrieval Attempts Rather Than Procedure Time Is Associated With Risk of Symptomatic Intracranial Hemorrhage. Stroke 2021; 52:1580-1588. [PMID: 33813864 PMCID: PMC8078115 DOI: 10.1161/strokeaha.120.031242] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. A direct association between the number of device passes and the occurrence of symptomatic intracranial hemorrhage (SICH) has been suggested. This study represents an in-depth investigation of the hypothesis that >3 retrieval attempts is associated with an increased rate of SICH in a large multicenter patient cohort. Methods: Two thousand six hundred eleven patients from the prospective German Stroke Registry were analyzed. Patients who received Endovascular therapy for acute large-vessel occlusion of the anterior circulation with known admission National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction, and number of retrieval passes were included. The primary outcome was defined as SICH. The secondary outcome was any type of radiologically confirmed intracranial hemorrhage within the first 24 hours. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers, as well as for confounders. Results: Five hundred ninety-three patients fulfilled the inclusion criteria. The median number of retrieval passes was 2 [interquartile range, 1–3]. SICH occurred in 26 cases (4.4%), whereas intracranial hemorrhage was identified by neuroimaging in 85 (14.3%) cases. More than 3 retrieval passes was the strongest predictor for SICH (odds ratio, 3.61 [95% CI, 1.38–9.42], P=0.0089) following adjustment for age, admission National Institutes of Health Stroke Scale, admission Alberta Stroke Program Early CT Score, and Thrombolysis in Cerebral Infarction, as well as time from symptom onset to flow restoration. Baseline Alberta Stroke Program Early CT Score of 8 to 9 (odds ratio, 0.26 [95% CI, 0.07–0.89], P=0.032) or 10 (odds ratio, 0.21 [95% CI, 0.06–0.78], P=0.020) were significant protective factors against the occurrence of SICH. Conclusions: More than 3 retrieval attempts is associated with a significant increase in SICH risk, regardless of patient age, baseline National Institutes of Health Stroke Scale, or procedure time. This should be considered when deciding whether to continue a procedure, especially in patients with large baseline infarctions. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.
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Affiliation(s)
- Máté Elöd Maros
- Department of Diagnostic and Interventional Neuroradiology (M.E.M., C.B., G.B., H.L., R.M., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neuroradiology (M.E.M.), Heidelberg University, Mannheim, Germany.,Department of Biomedical Informatics at the Center for Preventive Medicine and Digital Health, Medical Faculty Mannheim (M.E.M.), Heidelberg University, Mannheim, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology (M.E.M., C.B., G.B., H.L., R.M., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (M.E.M., C.B., G.B., H.L., R.M., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology (M.E.M., C.B., G.B., H.L., R.M., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology (M.E.M., C.B., G.B., H.L., R.M., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (M.E.M., C.B., G.B., H.L., R.M., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (M.E.M., C.B., G.B., H.L., R.M., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Faizy TD, Kabiri R, Christensen S, Mlynash M, Kuraitis GM, Broocks G, Flottmann F, Marks MP, Lansberg MG, Albers GW, Fiehler J, Wintermark M, Heit JJ. Favorable Venous Outflow Profiles Correlate With Favorable Tissue-Level Collaterals and Clinical Outcome. Stroke 2021; 52:1761-1767. [PMID: 33682452 DOI: 10.1161/strokeaha.120.032242] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Patients with acute ischemic stroke due to large vessel occlusion and favorable tissue-level collaterals (TLCs) likely have robust cortical venous outflow (VO). We hypothesized that favorable VO predicts robust TLC and good clinical outcomes. METHODS Multicenter retrospective cohort study of consecutive acute ischemic stroke due to large vessel occlusion patients who underwent thrombectomy triage. Included patients had interpretable prethrombectomy computed tomography, computed tomography angiography, and cerebral perfusion imaging. TLCs were measured on cerebral perfusion studies using the hypoperfusion intensity ratio (volume ratio of brain tissue with [Tmax >10 s/Tmax >6 s]). VO was determined by opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein on computed tomography angiography as 0, not visible; 1, moderate opacification; and 2, full. Clinical and demographic data were determined from the electronic medical record. Using multivariable regression analyses, we determined the association between VO and (1) favorable TLC status (defined as hypoperfusion intensity ratio ≤0.4) and (2) good functional outcome (modified Rankin Scale score, 0-2). RESULTS Six hundred forty-nine patients met inclusion criteria. Patients with favorable VO were younger (median age, 72 [interquartile range (IQR), 62-80] versus 77 [IQR, 66-84] years), had a lower baseline National Institutes of Health Stroke Scale (median, 12 [IQR, 7-17] versus 19 [IQR, 13-20]), and had a higher Alberta Stroke Program Early Computed Tomography Score (median, 9 [IQR, 7-10] versus 7 [IQR, 6-9]). Favorable VO strongly predicted favorable TLC (odds ratio, 4.5 [95% CI, 3.1-6.5]; P<0.001) in an adjusted regression analysis. Favorable VO also predicted good clinical outcome (odds ratio, 10 [95% CI, 6.2-16.0]; P<0.001), while controlling for favorable TLC, age, glucose, baseline National Institutes of Health Stroke Scale, and good vessel reperfusion status. CONCLUSIONS In this selective retrospective cohort study of acute ischemic stroke due to large vessel occlusion patients undergoing thrombectomy triage, favorable VO profiles correlated with favorable TLC and were associated with good functional outcomes after treatment. Future prospective studies should independently validate our findings.
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Affiliation(s)
- Tobias D Faizy
- Department of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.), Stanford University School of Medicine, CA
| | - Reza Kabiri
- Department of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.), Stanford University School of Medicine, CA
| | - Soren Christensen
- Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Gabriella M Kuraitis
- Department of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.), Stanford University School of Medicine, CA
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (G.B., F.F., J.F.)
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (G.B., F.F., J.F.)
| | - Michael P Marks
- Department of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.), Stanford University School of Medicine, CA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (G.B., F.F., J.F.)
| | - Max Wintermark
- Department of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.), Stanford University School of Medicine, CA
| | - Jeremy J Heit
- Department of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.), Stanford University School of Medicine, CA
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van Horn N, Kniep H, Broocks G, Meyer L, Flottmann F, Bechstein M, Götz J, Thomalla G, Bendszus M, Bonekamp S, Pfaff JAR, Dellani PR, Fiehler J, Hanning U. ASPECTS Interobserver Agreement of 100 Investigators from the TENSION Study. Clin Neuroradiol 2021; 31:1093-1100. [PMID: 33502563 PMCID: PMC8648648 DOI: 10.1007/s00062-020-00988-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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: 09/16/2020] [Accepted: 12/14/2020] [Indexed: 11/30/2022]
Abstract
Purpose Evaluating the extent of cerebral ischemic infarction is essential for treatment decisions and assessment of possible complications in patients with acute ischemic stroke. Patients are often triaged according to image-based early signs of infarction, defined by Alberta Stroke Program Early CT Score (ASPECTS). Our aim was to evaluate interrater reliability in a large group of readers. Methods We retrospectively analyzed 100 investigators who independently evaluated 20 non-contrast computed tomography (NCCT) scans as part of their qualification program for the TENSION study. Test cases were chosen by four neuroradiologists who had previously scored NCCT scans with ASPECTS between 0 and 8 and high interrater agreement. Percent and interrater agreements were calculated for total ASPECTS, as well as for each ASPECTS region. Results Percent agreements for ASPECTS ratings was 28%, with interrater agreement of 0.13 (95% confidence interval, CI 0.09–0.16), at zero tolerance allowance and 66%, with interrater agreement of 0.32 (95% CI: 0.21–0.44), at tolerance allowance set by TENSION inclusion criteria. ASPECTS region with highest level of agreement was the insular cortex (percent agreement = 96%, interrater agreement = 0.96 (95% CI: 0.94–0.97)) and with lowest level of agreement the M3 region (percent agreement = 68%, interrater agreement = 0.39 [95% CI: 0.17–0.61]). Conclusion Interrater agreement reliability for total ASPECTS and study enrollment was relatively low but seems sufficient for practical application. Individual region analysis suggests that some are particularly difficult to evaluate, with varying levels of reliability. Potential impairment of the supraganglionic region must be examined carefully, particularly with respect to the decision whether or not to perform mechanical thrombectomy.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Julia Götz
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Susanne Bonekamp
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | | | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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