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Alhazzani A, Al-Ajlan FS, Alkhiri A, Almaghrabi AA, Alamri AF, Alghamdi BA, Salamatullah HK, Alharbi AR, Almutairi MB, Chen HS, Wang Y, Abdalkader M, Turc G, Khatri P, Nguyen TN. Intravenous alteplase in minor nondisabling ischemic stroke: A systematic review and meta-analysis. Eur Stroke J 2024:23969873241237312. [PMID: 38465589 DOI: 10.1177/23969873241237312] [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: 03/12/2024] Open
Abstract
BACKGROUND Minor ischemic stroke, defined as National Institute of Health Stroke Scale score of 0-5 on admission, represents half of all acute ischemic strokes. The role of intravenous alteplase (IVA) among patients with minor stroke is inconclusive; therefore, we evaluated clinical outcomes of these patients treated with or without IVA. MATERIALS AND METHODS We searched Medline, Embase, Scopus, and the Cochrane library until August 1, 2023. Inclusion was restricted to the English literature of studies that reported on minor nondisabling stroke patients treated with or without IVA. Odds ratios (ORs) with their corresponding 95% CIs were utilized using a random-effects model. Efficacy outcomes included rates of excellent (modified Rankin scale [mRS] of 0-1) and good (mRS of 0-2) functional outcome at 90 days. The main safety outcome was symptomatic intracerebral hemorrhage (sICH). RESULTS Five eligible studies, two RCTs and three observational studies, comprising 2764 patients (31.8% female) met inclusion criteria. IVA was administered to 1559 (56.4%) patients. Pooled analysis of the two RCTs revealed no difference between the two groups in terms of 90-days excellent functional outcomes (OR 0.76 [95% CI, 0.51-1.13]; I2 = 0%) and sICH rates (OR 3.76 [95% CI, 0.61-23.20]). No significant differences were observed between the groups in terms of good functional outcomes, 90-day mortality, and 90-day stroke recurrence. CONCLUSION This meta-analysis of minor nondisabling stroke suggests that IVA did not prove more beneficial compared to no-IVA.
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Affiliation(s)
- Adel Alhazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed A Almaghrabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Aser F Alamri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Basil A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hassan K Salamatullah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdullah R Alharbi
- Department of Neurology, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Maher B Almutairi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | | | | | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
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Alkhiri A, Alamri AF, Alharbi AR, Almaghrabi AA, Alansari N, Niaz AA, Alghamdi BA, Sarraj A, Alhazzani A, Al-Ajlan FS. Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis. Eur Stroke J 2024; 9:69-77. [PMID: 37752802 PMCID: PMC10916830 DOI: 10.1177/23969873231201715] [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: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Isolated posterior cerebral artery occlusions (iPCAO) were underrepresented in pivotal randomized clinical trial (RCTs) of endovascular thrombectomy (EVT) in ischemic stroke, and the benefit of EVT in this population is still indeterminate. We performed a systematic review and a meta-analysis to compare the safety and efficacy of EVT compared to best medical management (BMM) in patients with iPCAO. METHODS We searched Medline/PubMed, Embase, Web of Science, and the Cochrane databases up to May 2023 for eligible studies reporting outcomes of patients with iPCAO treated with EVT or BMM. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI) using a random-effects model. RESULTS Seven studies involving 2560 patients were included. EVT was associated with significantly higher likelihood of early neurological improvement (OR, 2.31 [95% CI, 1.38-2.91]; p < 0.00001) and visual field normalization (OR, 3.08 [95% CI, 1.76-5.38]; p < 0.0001) compared to BMM. Rates of good functional outcomes (mRS 0-2) were comparable between the two arms (OR, 0.88 [95% CI, 0.70-1.10]; p = 0.26). Symptomatic intracranial hemorrhage (sICH) was comparable between the two groups (OR, 1.94 [95% CI, 0.96-3.93]; p = 0.07). Mortality was also similar between the two groups (OR, 1.36; [95% CI, 0.77-2.42]; p = 0.29). CONCLUSIONS In patients with iPCAO, EVT was associated with visual and early neurological improvement but with a strong trend toward increased sICH. Survival and functional outcomes may be slightly poorer. The role of EVT in iPCAO remains uncertain.
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Affiliation(s)
- Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Aser F Alamri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Ahmed A Almaghrabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Nayef Alansari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulelah A Niaz
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Basil A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Amrou Sarraj
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Adel Alhazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Alkhiri A, Al-Ajlan FS. Authors' response to 'Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis'. Eur Stroke J 2024; 9:276. [PMID: 38009692 PMCID: PMC10916824 DOI: 10.1177/23969873231216817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Alotaibi FF, Alshahrani A, Mohamed G, AlShamrani MA, Bin Amir H, Alsaeed A, Heji A, Alghanmi S, Alqurishi M, Alanazi A, Aldraye H, Asiri M, Alqahtani M, Alreshaid AA, AlKawi A, AlHazzani A, AlZawahmah M, Alokaili RN, Shuaib A, Al-Ajlan FS. Diagnostic accuracy of large and medium vessel occlusions in acute stroke imaging by neurology residents and stroke fellows: A comparison of CT angiography alone and CT angiography with CT perfusion. Eur Stroke J 2023:23969873231214218. [PMID: 37990504 DOI: 10.1177/23969873231214218] [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: 11/23/2023] Open
Abstract
INTRODUCTION Neurology senior residents and stroke fellows are first to clinically assess and interpret imaging studies of patients presenting to the emergency department with acute stroke. The aim of this study was to compare the diagnostic accuracy of brain CT angiography (CTA) with and without CT perfusion (CTP) between neurology senior residents and stroke fellows. METHODS In this neuroimaging study, nine practitioners (four senior neurology residents (SNRs) and five stroke fellows (SFs)) clinically assessed and interpreted the imaging data of 50 cases (15 normal images, 21 large vessel occlusions (LVOs) and 14 medium vessel occlusions (MeVOs) in two sessions, 1 week apart in comparison to final diagnosis of experienced neuroradiologist and experienced stroke neurologist consensus. Interrater agreement of CTA alone and CTA with CTP was quantified using kappa statistics, sensitivity, specificity and overall accuracy. RESULTS Overall, arterial occlusions were correctly identified in 221/315 (70.1%) with CTA alone and in 266/315 (84.4%) with CTA and CTP (p < 0.001). The sensitivity of overall arterial occlusions detection with CTA alone was 94.2% (95% CI: 90.8%-96.6%) while with addition of CTP was 98% (95% CI: 95.6%-99.3%), The specificity of CTA alone was 74.7% (95% CI: 67.2%-81.3%) which increased with CTP to 84.4% (95% CI: 77.7%-89.8%). The likelihood of correct identification with CTA alone was 156/189 (82.54%) for LVOs and 65/126 (51.59%) for MeVOs. This increased to 169/189 (89.42%; p = 0.054) for LVOs and 97/126 (76.98%; p < 0.001) for MeVOs when the CTA images with CTP were viewed. There was good overall interrater agreement between readers when using CTA alone (k 0.71, 95% CI, 0.62-0.80) and almost perfect (k 0.85, 95% CI, 0.76-0.94) when CTP was added to the image for interpretation. CTA and CTP had a significantly lower median interquartile range (IQR) interpretation time than CTA alone (114 [IQR, 103-120] s vs 156 [IQR, 133-160] s, p < 0.001). DISCUSSION In cerebral arterial occlusions, the rate of LVO and MeVOs detections increases when adding CTP to CTA. The accuracy and time for diagnosing arterial occlusion can be significantly improved if CTP is added to CTA. As MeVOs are commonly missed by front-line neurology senior residents or stroke fellows, cases with significant deficits and no apparent arterial occlusions need to be reviewed with neuroradiological expertise.
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Affiliation(s)
- Fawaz F Alotaibi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Asma Alshahrani
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gamal Mohamed
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed A AlShamrani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hussain Bin Amir
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ali Alsaeed
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Alaa Heji
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Suwaidi Alghanmi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alqurishi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Azhar Alanazi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hamad Aldraye
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Muhannad Asiri
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alqahtani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman A Alreshaid
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Ammar AlKawi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Adel AlHazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Mohamed AlZawahmah
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Riyadh N Alokaili
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Al-Ajlan FS, Gladstone DJ, Song D, Thorpe KE, Swartz RH, Butcher KS, Del Campo M, Dowlatshahi D, Gensicke H, Lee GJ, Flaherty ML, Hill MD, Aviv RI, Demchuk AM. Time Course of Early Hematoma Expansion in Acute Spot-Sign Positive Intracerebral Hemorrhage: Prespecified Analysis of the SPOTLIGHT Randomized Clinical Trial. Stroke 2023; 54:715-721. [PMID: 36756899 DOI: 10.1161/strokeaha.121.038475] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND In the SPOTLIGHT trial (Spot Sign Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy), patients with a computed tomography (CT) angiography spot-sign positive acute intracerebral hemorrhage were randomized to rFVIIa (recombinant activated factor VIIa; 80 μg/kg) or placebo within 6 hours of onset, aiming to limit hematoma expansion. Administration of rFVIIa did not significantly reduce hematoma expansion. In this prespecified analysis, we aimed to investigate the impact of delays from baseline imaging to study drug administration on hematoma expansion. METHODS Hematoma volumes were measured on the baseline CT, early post-dose CT, and 24 hours CT scans. Total hematoma volume (intracerebral hemorrhage+intraventricular hemorrhage) change between the 3 scans was calculated as an estimate of how much hematoma expansion occurred before and after studying drug administration. RESULTS Of the 50 patients included in the trial, 44 had an early post-dose CT scan. Median time (interquartile range) from onset to baseline CT was 1.4 hours (1.2-2.6). Median time from baseline CT to study drug was 62.5 (55-80) minutes, and from study drug to early post-dose CT was 19 (14.5-30) minutes. Median (interquartile range) total hematoma volume increased from baseline CT to early post-dose CT by 10.0 mL (-0.7 to 18.5) in the rFVIIa arm and 5.4 mL (1.8-8.3) in the placebo arm (P=0.96). Median volume change between the early post-dose CT and follow-up scan was 0.6 mL (-2.6 to 8.3) in the rFVIIa arm and 0.7 mL (-1.6 to 2.1) in the placebo arm (P=0.98). Total hematoma volume decreased between the early post-dose CT and 24-hour scan in 44.2% of cases (rFVIIa 38.9% and placebo 48%). The adjusted hematoma growth in volume immediately post dose for FVIIa was 0.998 times that of placebo ([95% CI, 0.71-1.43]; P=0.99). The hourly growth in FFVIIa was 0.998 times that for placebo ([95% CI, 0.994-1.003]; P=0.50; Table 3). CONCLUSIONS In the SPOTLIGHT trial, the adjusted hematoma volume growth was not associated with Factor VIIa treatment. Most hematoma expansion occurred between the baseline CT and the early post-dose CT, limiting any potential treatment effect of hemostatic therapy. Future hemostatic trials must treat intracerebral hemorrhage patients earlier from onset, with minimal delay between baseline CT and drug administration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01359202.
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Affiliation(s)
- Fahad S Al-Ajlan
- Department of Neurosciences (Neurology), King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - David J Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dongbeom Song
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Kevin E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Canada (K.E.T.)
| | - Rick H Swartz
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, AustraliaDepartment of Medicine (Neurology), University of Alberta, Edmonton, Canada (K.S.B.)
| | - Martin Del Campo
- Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | - Henrik Gensicke
- Stroke Center and Neurology, University Hospital Basel, Switzerland (H.G.)
| | - Gloria Jooyoung Lee
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Richard I Aviv
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
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Ohara T, Menon BK, Al-Ajlan FS, Horn M, Najm M, Al-Sultan A, Puig J, Dowlatshahi D, Calleja Sanz AI, Sohn SI, Ahn SH, Poppe AY, Mikulik R, Asdaghi N, Field TS, Jin A, Asil T, Boulanger JM, Letteri F, Dey S, Evans JW, Goyal M, Hill MD, Almekhlafi M, Demchuk AM. Thrombus Migration and Fragmentation After Intravenous Alteplase Treatment: The INTERRSeCT Study. Stroke 2020; 52:203-212. [PMID: 33317416 DOI: 10.1161/strokeaha.120.029292] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE There is interest in what happens over time to the thrombus after intravenous alteplase. We study the effect of alteplase on thrombus structure and its impact on clinical outcome in patients with acute stroke. METHODS Intravenous alteplase treated stroke patients with intracranial internal carotid artery or middle cerebral artery occlusion identified on baseline computed tomography angiography and with follow-up vascular imaging (computed tomography angiography or first run of angiography before endovascular therapy) were enrolled from INTERRSeCT study (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography). Thrombus movement after intravenous alteplase was classified into complete recanalization, thrombus migration, thrombus fragmentation, and no change. Thrombus migration was diagnosed when occlusion site moved distally and graded according to degrees of thrombus movement (grade 0-3). Thrombus fragmentation was diagnosed when a new distal occlusion in addition to the primary occlusion was identified on follow-up imaging. The association between thrombus movement and clinical outcome was also evaluated. RESULTS Among 427 patients in this study, thrombus movement was seen in 54% with a median time of 123 minutes from alteplase administration to follow-up imaging, and sub-classified as marked (thrombus migration grade 2-3 + complete recanalization; 27%) and mild to moderate thrombus movement (thrombus fragmentation + thrombus migration grade 0-1; 27%). In patients with proximal M1/internal carotid artery occlusion, marked thrombus movement was associated with a higher rate of good outcome (90-day modified Rankin Scale, 0-2) compared with mild to moderate movement (52% versus 27%; adjusted odds ratio, 5.64 [95% CI, 1.72-20.10]). No difference was seen in outcomes between mild to moderate thrombus movement and no change. In M1 distal/M2 occlusion, marked thrombus movement was associated with improved 90-day good outcome compared with no change (70% versus 56%; adjusted odds ratio, 2.54 [95% CI, 1.21-5.51]). CONCLUSIONS Early thrombus movement is common after intravenous alteplase. Marked thrombus migration leads to good clinical outcomes. Thrombus dynamics over time should be further evaluated in clinical trials of acute reperfusion therapy.
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Affiliation(s)
- Tomoyuki Ohara
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.).,Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan (T.O.)
| | - Bijoy K Menon
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Fahad S Al-Ajlan
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - MacKenzie Horn
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Mohamed Najm
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Abdulaziz Al-Sultan
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Josep Puig
- IDI-IDIBGI, Dr Josep Trueta University Hospital, Girona, Spain (J.P.)
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | - Ana I Calleja Sanz
- Department of Neurology, Universitary Clinical Hospital of Valladolid, Spain (A.I.C.-S.)
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University, Daegu, Republic of Korea (S.-I.S.)
| | - Seong H Ahn
- Gwangju Institute of Science and Technology, Republic of Korea (S.H.A.)
| | - Alexandre Y Poppe
- Department of Neurosciences, University of Montreal, Canada (A.Y.P.)
| | - Robert Mikulik
- International Clinical Research Center, Department of Neurology, St Anne's University Hospital, Masaryk University, Brno, Czech Republic (R.M.)
| | | | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (T.S.F.)
| | - Albert Jin
- Department of Medicine (Neurology), Queen's University, Kingston, Ontario, Canada (A.J.)
| | - Talip Asil
- Bezmialem Vakif Univesitesi Noroloji, Istanbul, Turkey (T.A.)
| | | | - Federica Letteri
- Istituto Don Calabria, IRCCS Sacro Cuore Hospital, Negrar, Italy (F.L.)
| | | | | | - Mayank Goyal
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Michael D Hill
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Mohammed Almekhlafi
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Andrew M Demchuk
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
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Ganesh A, Menon BK, Assis ZA, Demchuk AM, Al-Ajlan FS, Al-Mekhlafi MA, Rempel JL, Shuaib A, Baxter BW, Devlin T, Thornton J, Williams D, Poppe AY, Roy D, Krings T, Casaubon LK, Kashani N, Hill MD, Goyal M. Discrepancy between post-treatment infarct volume and 90-day outcome in the ESCAPE randomized controlled trial. Int J Stroke 2020; 16:593-601. [PMID: 32515694 DOI: 10.1177/1747493020929943] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Some patients with ischemic stroke have poor outcomes despite small infarcts after endovascular thrombectomy, while others with large infarcts sometimes fare better. AIMS We explored factors associated with such discrepancies between post-treatment infarct volume (PIV) and functional outcome. METHODS We identified patients with small PIV (volume ≤ 25th percentile) and large PIV (volume ≥ 75th percentile) on 24-48-h CT/MRI in the ESCAPE randomized-controlled trial. Demographics, comorbidities, baseline, and 24-48-h stroke severity (NIHSS), stroke location, treatment type, post-stroke complications, and other outcome scales like Barthel Index, and EQ-5D were compared between "discrepant cases" - those with 90-day modified Rankin Scale(mRS) ≤ 2 despite large PIV or mRS ≥ 3 despite small PIV - and "non-discrepant cases". Multi-variable logistic regression was used to identify pre-treatment and post-treatment factors associated with small-PIV/mRS ≥ 3 and large-PIV/mRS ≤ 2. Sensitivity analyses used different definitions of small/large PIV and good/poor outcome. RESULTS Among 315 patients, median PIV was 21 mL; 27/79 (34.2%) patients with PIV ≤ 7 mL (25th percentile) had mRS ≥ 3; 12/80 (15.0%) with PIV ≥ 72 mL (75th percentile) had mRS ≤ 2. Discrepant cases did not differ by CT versus MRI-based PIV ascertainment, or right versus left-hemisphere involvement (p = 0.39, p = 0.81, respectively, for PIV ≤ 7 mL/mRS ≥ 3). Pre-treatment factors independently associated with small-PIV/mRS ≥ 3 included older age (p = 0.010), cancer, and vascular risk-factors; post-treatment factors included 48-h NIHSS (p = 0.007) and post-stroke complications (p = 0.026). Absence of vascular risk-factors (p = 0.004), CT-based lentiform nucleus sparing (p = 0.002), lower 24-hour NIHSS (p = 0.001), and absence of complications (p = 0.013) were associated with large-PIV/mRS ≤ 2. Sensitivity analyses yielded similar results. CONCLUSIONS Discrepancies between functional ability and PIV are likely explained by differences in age, comorbidities, and post-stroke complications, emphasizing the need for high-quality post-thrombectomy stroke care. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01778335.
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Affiliation(s)
- Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Calgary, Canada
| | - Zarina A Assis
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Calgary, Canada
| | - Fahad S Al-Ajlan
- Department of Neurosciences, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Mohammed A Al-Mekhlafi
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Calgary, Canada
| | - Jeremy L Rempel
- Department of Radiology, University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Stroke Program and Department of Medicine, University of Alberta, Edmonton, Canada
| | - Blaise W Baxter
- Department of Radiology, University of Tennessee, Erlanger Hospital, Knoxville, TN, USA
| | - Thomas Devlin
- Department of Neurology, University of Tennessee, Erlanger Hospital, Knoxville, TN, USA
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David Williams
- Department of Geriatric & Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Alexandre Y Poppe
- Department of Neurosciences, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Canada
| | - Daniel Roy
- Department of Radiology, CHUM, Université de Montréal, Montreal, Canada
| | - Timo Krings
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Canada
| | - Leanne K Casaubon
- Division of Neurology, Stroke Program, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Canada
| | - Nima Kashani
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Calgary, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Calgary, Canada
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8
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Dowlatshahi D, Morotti A, Al-Ajlan FS, Boulouis G, Warren AD, Petrcich W, Aviv RI, Demchuk AM, Goldstein JN. Interrater and Intrarater Measurement Reliability of Noncontrast Computed Tomography Predictors of Intracerebral Hemorrhage Expansion. Stroke 2020; 50:1260-1262. [PMID: 30909839 DOI: 10.1161/strokeaha.118.024050] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Early hematoma expansion after intracerebral hemorrhage is a potentially modifiable predictor of outcome and a promising therapeutic target. Radiological markers seen on noncontrast computed tomography can help predict hematoma expansion and risk stratify patients presenting with intracerebral hemorrhage. Our objective was to assess the interrater and intrarater reliability of 5 commonly reported noncontrast computed tomographic markers of hematoma expansion. Methods- Four readers independently reviewed images from 40 patients from 2 intracerebral hemorrhage imaging databases (PREDICT Collaboration [Predicting Haematoma Growth and Outcome in Intracerebral Haemorrhage Using Contrast Bolus CT] and Massachusetts General Hospital). Readers were blind to all demographic and outcome data and used accepted definitions to establish the presence or absence of intrahematoma hypodensities, blend sign, fluid level, irregular hematoma morphology, and heterogeneous hematoma density. We calculated interrater and intrarater agreement and stratified kappas for the 5 imaging markers. Results- Interrater agreement was excellent for all 5 markers, ranging from 94% to 98%. Interrater kappas ranged from 0.67 to 0.91 (the lowest for fluid level). Interrater agreement had a similar pattern, ranging from 89% to 93%, with Kappas ranging from 0.60 to 0.89. Conclusions- We show that 5 commonly used noncontrast computed tomographic imaging findings all have good-to-excellent interrater and intrarater reliabilities, with the best kappa for blend sign, hypodensities, and heterogeneity.
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Affiliation(s)
- Dar Dowlatshahi
- From the Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., W.P.)
| | - Andrea Morotti
- Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy (A.M.)
| | - Fahad S Al-Ajlan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - Gregoire Boulouis
- Department of Neuroradiology, Université Paris Descartes, Centre Hospitalier Sainte-Anne, France (G.B.)
| | - Andrew D Warren
- Massachusetts General Hospital, Harvard Medical School, Boston (A.D.W.)
| | - William Petrcich
- From the Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Canada (D.D., W.P.)
| | - Richard I Aviv
- Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada.,Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (A.M.D.), Hotchkiss Brain Institute, University of Calgary, Canada.,Department of Radiology (A.M.D.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Joshua N Goldstein
- Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston.,J.P. Kistler Stroke Research Center (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
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9
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Boers AMM, Jansen IGH, Brown S, Lingsma HF, Beenen LFM, Devlin TG, Román LS, Heo JH, Ribó M, Almekhlafi MA, Liebeskind DS, Teitelbaum J, Cuadras P, du Mesnil de Rochemont R, Beaumont M, Brown MM, Yoo AJ, Donnan GA, Mas JL, Oppenheim C, Dowling RJ, Moulin T, Agrinier N, Lopes DK, Aja Rodríguez L, Compagne KCJ, Al-Ajlan FS, Madigan J, Albers GW, Soize S, Blasco J, Davis SM, Nogueira RG, Dávalos A, Menon BK, van der Lugt A, Muir KW, Roos YBWEM, White P, Mitchell PJ, Demchuk AM, van Zwam WH, Jovin TG, van Oostenbrugge RJ, Dippel DWJ, Campbell BCV, Guillemin F, Bracard S, Hill MD, Goyal M, Marquering HA, Majoie CBLM. Mediation of the Relationship Between Endovascular Therapy and Functional Outcome by Follow-up Infarct Volume in Patients With Acute Ischemic Stroke. JAMA Neurol 2019; 76:194-202. [PMID: 30615038 DOI: 10.1001/jamaneurol.2018.3661] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance The positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke. Objective To study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke. Design, Setting, and Participants Patient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017. Main Outcome and Measure The 90-day functional outcome via the modified Rankin Scale (mRS). Results Among 1665 patients, the median (interquartile range [IQR]) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median [IQR] FIV, 33 [11-99] vs 51 [18-134] mL; P = .007) and lower mRS scores at 90 days (median [IQR] score, 3 [1-4] vs 4 [2-5]). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome. Conclusions and Relevance In this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.
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Affiliation(s)
- Anna M M Boers
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands
| | - Ivo G H Jansen
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Scott Brown
- Altair Biostatistics, Mooresville, North Carolina
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Thomas G Devlin
- Department of Neurology, Erlanger Hospital, University of Tennessee at Chattanooga
| | - Luis San Román
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Catalonia, Spain
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University, Seoul, South Korea
| | - Marc Ribó
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Catalonia, Spain
| | - Mohammed A Almekhlafi
- Department of Neurology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Jeanne Teitelbaum
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - Patricia Cuadras
- Department of Radiology, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | | | - Marine Beaumont
- Inserm CIC-IT 1433, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Martin M Brown
- Institute of Neurology, University College London, London, United Kingdom
| | - Albert J Yoo
- Division of Neurointervention, Texas Stroke Institute, Dallas
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Jean Louis Mas
- Department of Neurology, Sainte-Anne Hospital and Paris-Descartes University, INSERM U894, Paris, France
| | - Catherine Oppenheim
- Department of Neuroradiology, Sainte-Anne Hospital and Paris-Descartes University, INSERM U894, Paris, France
| | - Richard J Dowling
- Department of Radiology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Thierry Moulin
- Department of Neurology, University Hospital of Besançon, University of Franche-Comté, Besançon, France
| | - Nelly Agrinier
- Inserm, Centre Hospitalier Régional et Universitaire de Nancy, Université de Lorraine, CIC1433-Epidémiologie Clinique, Nancy, France
| | - Demetrius K Lopes
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Lucía Aja Rodríguez
- Neuroradiology Department, Hospital Universitari de Bellvitge, Barcelona, Catalonia, Spain
| | - Kars C J Compagne
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fahad S Al-Ajlan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Gregory W Albers
- Department of Neurology, Stanford Stroke Center, Palo Alto, California
| | - Sebastien Soize
- Department of Neuroradiology, University Hospital of Reims, Reims, France
| | - Jordi Blasco
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Catalonia, Spain
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Raul G Nogueira
- Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Peter J Mitchell
- Department of Radiology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Tudor G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Francis Guillemin
- Inserm, Centre Hospitalier Régional et Universitaire de Nancy, Université de Lorraine, CIC1433-Epidémiologie Clinique, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, INSERM U947, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
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10
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Ohara T, Menon BK, Al-Ajlan FS, Horn M, Al Sultan AS, Letteri F, Dey S, Evans J, Najm M, Puig J, Dowlatshahi D, Calleja A, Sohn SI, Ahn SH, Poppe A, Mikulik R, Asdaghi N, Field TS, Jin A, Asil T, Boulanger JM, Goyal M, Hill MD, Almekhlafi M, Demchuk AM. Abstract 82: Thrombus Migration is a Common Phenomenon With IV TPA and May Have Negative Effects on Outcome When TPA Treatment is Given Before Endovascular Thrombectomy in Proximal Occlusions. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
There is interest in understanding thrombus dynamics from IV TPA prior to endovascular thrombectomy (EVT) given the possible dichotomy amongst sites of occlusion for IV TPA benefit/harm. Kaesmacher et al reported beneficial 5+% rates of early TICI
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2a reperfusion in distal M1 or M2 MCA occlusions with IV TPA. However in more proximal occlusions this was rare; and potentially harmful worsening of perfusion seen with change of occlusion site. We aimed to examine IV TPA related thrombus dynamics including migration further across both proximal and distal occlusions in a multicenter prospective cohort study INTERRSeCT.
Methods:
Acute ischemic stroke patients with intracranial occlusion who had baseline CTA and follow-up CTA or initial run angio in INTERRSeCT and IV TPA were reviewed. We evaluated change of occlusion site (COS) and classified patients into 4 categories: Complete Recanalization (CR) of primary occlusive lesion with no remaining thrombus; definite Thrombus Migration (dTM) with primary occlusion site moved to a distal artery and occlusion site patent on baseline CTA; probable Thrombus Migration (pTM) with COS evident but initial occlusion extent not visualized; or No Change of occlusion site (NC).
Results:
A total of 462 IV TPA patients were enrolled, 41% received EVT. Median time from TPA to follow-up imaging was 133 minutes. COS was seen in 50% of cases with CR in 15% and TM in 35% (dTM 12%, pTM 23%). Distal artery occlusion and longer interval of TPA to imaging were independent predictors for COS. In 62 proximal occlusion (ICA and proximal-mid M1 MCA) patients with follow-up imaging within 60 mins after TPA (receiving EVT in 94%), any TM showed a lower rate of 90-day mRS≤2 than NC (47% vs 78%, adjusted OR 0.21, 95%CI 0.04-0.87). No CR was seen in this early group.
Conclusions:
Thrombus migration is common after IV TPA. Thrombus instability from IV TPA may worsen clinical outcome in proximal occlusions despite early EVT initiation, possibly due to migration of thrombus to distal arteries accelerating infarction or more challenging thrombectomy due to thrombus dispersion. The benefit of IV TPA prior to EVT at comprehensive stroke centers for ICA or prox-mid M1 occlusions require more study in randomized clinical trials.
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Affiliation(s)
- Tomoyuki Ohara
- Calgary stroke program, Dept of Clinical Neurosciences, Univ of Calgary, Calgary, Canada
| | | | | | | | | | | | | | | | | | - Josep Puig
- Univ Hosp Dr Josep Trueta-IDI-IDIBGI, Girona, Spain
| | | | - Ana Calleja
- Univ de Valladolid, Univ de Valladolid, Spain
| | | | - Seong H Ahn
- Gwangju Inst of Science and Technology, Gwangju, Korea, Republic of
| | | | | | | | | | | | - Talip Asil
- Bezmialem Vakif Univesitesi Noroloji, Istanbul, Turkey
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11
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Abusrair AH, Bohlega S, Al-Semari A, Al-Ajlan FS, Al-Ahmadi K, Mohamed B, AlDakheel A. Brain MR Imaging Findings in Woodhouse-Sakati Syndrome. AJNR Am J Neuroradiol 2018; 39:2256-2262. [PMID: 30409855 DOI: 10.3174/ajnr.a5879] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/29/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND PURPOSE Woodhouse-Sakati syndrome is a rare autosomal recessive disorder characterized by hypogonadism, alopecia, diabetes mellitus, and progressive extrapyramidal signs. The disease is caused by biallelic pathogenic variants in the DCAF17 gene. The purpose of this study was to describe the spectrum of brain MR imaging abnormalities in Woodhouse-Sakati syndrome. MATERIALS AND METHODS We reviewed brain MR images of 26 patients with a clinical and genetic diagnosis of Woodhouse-Sakati syndrome (12 males, 14 females; age range, 16-45 years; mean age, 26.6 years). Follow-up studies were conducted for 6 patients. RESULTS All patients had abnormal MR imaging findings. The most common abnormalities were a small pituitary gland (76.9%), pronounced basal ganglia iron deposition (73%), and white matter lesions in 69.2%. White matter lesions showed frontoparietal and periventricular predominance. All white matter lesions spared subcortical U-fibers and were nonenhanced. Prominent perivascular spaces (15.3%) and restricted diffusion in the splenium of the corpus callosum (7.6%) were less frequent findings. Follow-up studies showed expansion of white matter lesions with iron deposition further involving the red nucleus and substantia nigra. Older age was associated with a more severe degree of white matter lesions (P < .001). CONCLUSIONS Small pituitary gland, accentuated iron deposition in the globus pallidus, and nonenhancing frontoparietal/periventricular white matter lesions were the most noted abnormalities seen in our cohort. The pattern and extent of these findings were observed to correlate with older age, reflecting a possible progressive myelin destruction and/or axonal loss. The presence of pituitary hypoplasia and white matter lesions can further distinguish Woodhouse-Sakati syndrome from other neurodegenerative diseases with brain iron accumulation subtypes.
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Affiliation(s)
- A H Abusrair
- From the Departments of Neurosciences (A.H.A., S.B., A.A.-S., F.S.A.-A., B.M., A.A.)
| | - S Bohlega
- From the Departments of Neurosciences (A.H.A., S.B., A.A.-S., F.S.A.-A., B.M., A.A.)
| | - A Al-Semari
- From the Departments of Neurosciences (A.H.A., S.B., A.A.-S., F.S.A.-A., B.M., A.A.)
| | - F S Al-Ajlan
- From the Departments of Neurosciences (A.H.A., S.B., A.A.-S., F.S.A.-A., B.M., A.A.)
| | - K Al-Ahmadi
- Radiology (K.A.-A.), King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - B Mohamed
- From the Departments of Neurosciences (A.H.A., S.B., A.A.-S., F.S.A.-A., B.M., A.A.)
| | - A AlDakheel
- From the Departments of Neurosciences (A.H.A., S.B., A.A.-S., F.S.A.-A., B.M., A.A.)
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12
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Menon BK, Al-Ajlan FS, Najm M, Puig J, Castellanos M, Dowlatshahi D, Calleja A, Sohn SI, Ahn SH, Poppe A, Mikulik R, Asdaghi N, Field TS, Jin A, Asil T, Boulanger JM, Smith EE, Coutts SB, Barber PA, Bal S, Subramanian S, Mishra S, Trivedi A, Dey S, Eesa M, Sajobi T, Goyal M, Hill MD, Demchuk AM. Association of Clinical, Imaging, and Thrombus Characteristics With Recanalization of Visible Intracranial Occlusion in Patients With Acute Ischemic Stroke. JAMA 2018; 320:1017-1026. [PMID: 30208455 PMCID: PMC6143104 DOI: 10.1001/jama.2018.12498] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Recanalization of intracranial thrombus is associated with improved clinical outcome in patients with acute ischemic stroke. The association of intravenous alteplase treatment and thrombus characteristics with recanalization over time is important for stroke triage and future trial design. OBJECTIVE To examine recanalization over time across a range of intracranial thrombus occlusion sites and clinical and imaging characteristics in patients with ischemic stroke treated with intravenous alteplase or not treated with alteplase. DESIGN, SETTING, AND PARTICIPANTS Multicenter prospective cohort study of 575 patients from 12 centers (in Canada, Spain, South Korea, the Czech Republic, and Turkey) with acute ischemic stroke and intracranial arterial occlusion demonstrated on computed tomographic angiography (CTA). EXPOSURES Demographics, clinical characteristics, time from alteplase to recanalization, and intracranial thrombus characteristics (location and permeability) defined on CTA. MAIN OUTCOMES AND MEASURES Recanalization on repeat CTA or on first angiographic acquisition of affected intracranial circulation obtained within 6 hours of baseline CTA, defined using the revised arterial occlusion scale (rAOL) (scores from 0 [primary occlusive lesion remains the same] to 3 [complete revascularization of primary occlusion]). RESULTS Among 575 patients (median age, 72 years [IQR, 63-80]; 51.5% men; median time from patient last known well to baseline CTA of 114 minutes [IQR, 74-180]), 275 patients (47.8%) received intravenous alteplase only, 195 (33.9%) received intravenous alteplase plus endovascular thrombectomy, 48 (8.3%) received endovascular thrombectomy alone, and 57 (9.9%) received conservative treatment. Median time from baseline CTA to recanalization assessment was 158 minutes (IQR, 79-268); median time from intravenous alteplase start to recanalization assessment was 132.5 minutes (IQR, 62-238). Successful recanalization occurred at an unadjusted rate of 27.3% (157/575) overall, including in 30.4% (143/470) of patients who received intravenous alteplase and 13.3% (14/105) who did not (difference, 17.1% [95% CI, 10.2%-25.8%]). Among patients receiving alteplase, the following factors were associated with recanalization: time from treatment start to recanalization assessment (OR, 1.28 for every 30-minute increase in time [95% CI, 1.18-1.38]), more distal thrombus location, eg, distal M1 middle cerebral artery (39/84 [46.4%]) vs internal carotid artery (10/92 [10.9%]) (OR, 5.61 [95% CI, 2.38-13.26]), and higher residual flow (thrombus permeability) grade, eg, hairline streak (30/45 [66.7%]) vs none (91/377 [24.1%]) (OR, 7.03 [95% CI, 3.32-14.87]). CONCLUSIONS AND RELEVANCE In patients with acute ischemic stroke, more distal thrombus location, greater thrombus permeability, and longer time to recanalization assessment were associated with recanalization of arterial occlusion after administration of intravenous alteplase; among patients who did not receive alteplase, rates of arterial recanalization were low. These findings may help inform treatment and triage decisions in patients with acute ischemic stroke.
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Affiliation(s)
| | - Fahad S. Al-Ajlan
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Josep Puig
- IDI-IDIBGI, Dr Josep Trueta University Hospital, Girona, Spain
| | - Mar Castellanos
- IDI-IDIBGI, Dr Josep Trueta University Hospital, Girona, Spain
| | | | - Ana Calleja
- Universidad de Valladolid, Valladolid, Spain
| | | | - Seong H. Ahn
- Keimyung University, Daegu, Republic of Korea
- Gwangju Institute of Science and Technology, Gwangju, Republic of Korea
| | - Alex Poppe
- University of Montreal, Montreal, Québec, Canada
| | - Robert Mikulik
- International Clinical Research Center, Department of Neurology, St Ann's University Hospital, Masaryk University, Brno, Czech Republic
| | | | - Thalia S. Field
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Albert Jin
- Queen's University Kingston, Ontario, Canada
| | - Talip Asil
- Bezmialem Vakif Univesitesi Noroloji, Istanbul, Turkey
| | | | | | | | | | | | | | - Sachin Mishra
- Gold Coast University Hospital, Gold Coast, Australia
| | | | | | - Muneer Eesa
- University of Calgary, Calgary, Alberta, Canada
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13
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Boers AMM, Jansen IGH, Beenen LFM, Devlin TG, San Roman L, Heo JH, Ribó M, Brown S, Almekhlafi MA, Liebeskind DS, Teitelbaum J, Lingsma HF, van Zwam WH, Cuadras P, du Mesnil de Rochemont R, Beaumont M, Brown MM, Yoo AJ, van Oostenbrugge RJ, Menon BK, Donnan GA, Mas JL, Roos YBWEM, Oppenheim C, van der Lugt A, Dowling RJ, Hill MD, Davalos A, Moulin T, Agrinier N, Demchuk AM, Lopes DK, Aja Rodríguez L, Dippel DWJ, Campbell BCV, Mitchell PJ, Al-Ajlan FS, Jovin TG, Madigan J, Albers GW, Soize S, Guillemin F, Reddy VK, Bracard S, Blasco J, Muir KW, Nogueira RG, White PM, Goyal M, Davis SM, Marquering HA, Majoie CBLM. Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials. J Neurointerv Surg 2018; 10:1137-1142. [DOI: 10.1136/neurintsurg-2017-013724] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/26/2018] [Accepted: 03/02/2018] [Indexed: 11/04/2022]
Abstract
BackgroundFollow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement.ObjectiveTo examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality.MethodsData of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated.ResultsOf 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14–120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15–131) vs 22 mL (IQR 8–71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively).ConclusionsIn patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.
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14
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Alqwaifly M, Al-Ajlan FS, Al-Hindi H, Al Semari A. Central Nervous System Brucellosis Granuloma and White Matter Disease in Immunocompromised Patient. Emerg Infect Dis 2018; 23:978-981. [PMID: 28518039 PMCID: PMC5443428 DOI: 10.3201/eid2306.161173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Brucellosis is a multisystem zoonotic disease. We report an unusual case of neurobrucellosis with seizures in an immunocompromised patient in Saudi Arabia who underwent renal transplantation. Magnetic resonance imaging of the brain showed diffuse white matter lesions. Serum and cerebrospinal fluid were positive for Brucella sp. Granuloma was detected in a brain biopsy specimen.
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15
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Al Sultan AS, Al-Ajlan FS, Najm M, Casault C, Neweduk A, Horn M, Field TS, Puig J, Castellanos M, Dowlatshahi D, Sohn SII, Ahn SH, Poppe A, Mikulik R, Asdaghi N, Boulanger JM, Asil T, Calleja AI, Goyal M, Hill MD, Demchuk AM, Menon BK. Abstract WP62: Favorable Clot Characteristics Predict Smaller Infarct Volume in Acute Ischemic Stroke Patients Treated With Reperfusion Therapy. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Multiple studies have correlated larger final infarct volume (FIV) with worse clinical outcomes. In
INTERRSeCT
, an international multicenter prospective cohort study, we sought to determine the favorable intracranial clot characteristics predicting smaller infarct volumes.
Methods:
FIV was measured (24 ±12 hours after baseline imaging) in 605 patients from
INTERRSeCT
study by blinded readers using Quantomo (Cybertrial Inc, Calgary). Clot Burden Score (CBS) is a 10-point scale with 10 referring to a completely patent ipsilateral anterior circulation from ICA to both M2 arteries, whereas 0 refers to a completely occluded ipsilateral anterior circulation. Residual Flow Grade (RFG) assesses the radiological permeability of the clot to contrast, with grade 0, 1, and 2 defined as no contrast, diffuse ghosting, and hairline lumen, respectively. Both of these scores were assessed by a blinded reader to the FIV. Using ordinal logistic regression, FIV was divided into deciles as the outcome. CBS and RFG were analyzed from 0 to 10, and 0 to 2, respectively. Two models were used, the first has no recanalization status, while the second included it.
Results:
The median FIVs with and without recanalization were 12.34 ml (IQR: 32.3 ml) and 22.15 ml (IQR: 60.12ml), respectively. CBS and RFG were independently predictive of FIV (p-value= <0.001 and 0.003, respectively). The common ORs for having one decile higher FIV for 1 point increase in CBS and RFG were 0.82 (CI: 0.77, 0.87) and 0.66 (CI: 0.51, 0.86), respectively. After adjusting for recanalization, the common ORs for having one decile higher FIV for 1 point increase in CBS and RFG were 0.83 (CI: 0.78, 0.88) and 0.72 (CI: 0.54, 0.94), respectively.
Conclusions:
Residual flow grade and clot burden score are fast and practical techniques for practitioners treating acute ischemic stroke patients. Favorable RFG and CBS independently, predict lower infarct volumes regardless of whether recanalization achieved.
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Affiliation(s)
| | | | - Mohammed Najm
- Univ of Calgary - Foothills Med Cntr, Calgary, Canada
| | - Colin Casault
- Univ of Calgary - Foothills Med Cntr, Calgary, Canada
| | | | | | | | - Josep Puig
- Inst de Diagnostic per la Imatge (IDI) Girona, Girona, Spain
| | - Mar Castellanos
- Inst de Diagnostic per la Imatge (IDI) Girona, Girona, Spain
| | | | | | - Seong H Ahn
- Chosun Univ Sch of Medicine, Dong-gu, GwangJu, Korea, Republic of
| | | | | | | | | | | | | | - Mayank Goyal
- Univ of Calgary - Foothills Med Cntr, Calgary, Canada
| | | | | | - Bijoy K Menon
- Univ of Calgary - Foothills Med Cntr, Calgary, Canada
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16
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Evans JW, Graham BR, Pordeli P, Al-Ajlan FS, Willinsky R, Montanera WJ, Rempel JL, Shuaib A, Brennan P, Williams D, Roy D, Poppe AY, Jovin TG, Devlin T, Baxter BW, Krings T, Silver FL, Frei DF, Fanale C, Tampieri D, Teitelbaum J, Iancu D, Shankar J, Barber PA, Demchuk AM, Goyal M, Hill MD, Menon BK. Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial. AJNR Am J Neuroradiol 2017; 39:102-106. [PMID: 29191873 DOI: 10.3174/ajnr.a5462] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/15/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.
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Affiliation(s)
- J W Evans
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - B R Graham
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - P Pordeli
- Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - F S Al-Ajlan
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - R Willinsky
- Department of Medical Imaging (R.W., W.J.M.)
| | | | | | - A Shuaib
- Medicine (Neurology) (A.S.), University of Alberta, Edmonton, Alberta, Canada
| | - P Brennan
- Departments of Neuroradiology (P.B.)
| | - D Williams
- Geriatric and Stroke Medicine (D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - D Roy
- Departments of Radiology (D.R.)
| | - A Y Poppe
- Neurosciences (A.Y.P.), Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - T G Jovin
- Department of Neurology (T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - B W Baxter
- Department of Radiology (B.W.B), Erlanger Hospital, University of Tennessee, Chattanooga, Tennessee
| | | | - F L Silver
- Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - D F Frei
- Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado
| | - C Fanale
- Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - D Tampieri
- Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado
| | - J Teitelbaum
- Montreal Neurological Institute (J.T.), McGill University, Montreal, Quebec, Canada
| | - D Iancu
- Department of Radiology (D.I.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J Shankar
- Department of Neuroradiology (J.S.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - P A Barber
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M D Hill
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.) .,Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada.,Foothills Medical Centre (B.K.M.), Calgary, Alberta, Canada
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17
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Al-Ajlan FS, Al Sultan AS, Minhas P, Assis Z, de Miquel MA, Millán M, San Román L, Tomassello A, Demchuk AM, Jovin TG, Cuadras P, Dávalos A, Goyal M, Menon BK. Posttreatment Infarct Volumes when Compared with 24-Hour and 90-Day Clinical Outcomes: Insights from the REVASCAT Randomized Controlled Trial. AJNR Am J Neuroradiol 2017; 39:107-110. [PMID: 29170266 DOI: 10.3174/ajnr.a5463] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 08/16/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy has become the standard of care for patients with disabling anterior circulation ischemic stroke due to proximal intracranial thrombi. Our aim was to determine whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in posttreatment infarct volume in the Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT) trial. MATERIALS AND METHODS The REVASCAT trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 206 enrolled subjects (endovascular treatment, n = 103; control, n = 103), posttreatment infarct volume was measured in 204 subjects. Posttreatment infarct volumes were compared with treatment assignment and recanalization status. Appropriate statistical models were used to assess the relationship among baseline clinical and imaging variables, posttreatment infarct volume, the 24-hour NIHSS score, and functional status with the 90-day modified Rankin Scale score. RESULTS The median posttreatment infarct volume in all subjects was 23.7 mL (interquartile range = 68.9 mL) and 16.3 mL (interquartile range = 50.2 mL) in the endovascular treatment arm and 38.6 mL (interquartile range = 74.9 mL) in the control arm (P = .02 for endovascular treatment versus control subjects). Baseline NIHSS (P < .01), site of occlusion (P < .03), baseline NCCT ASPECTS (P < .01), and recanalization status (P = .02) were independently associated with posttreatment infarct volume. Baseline NIHSS (P < .01), time from symptom onset to randomization (P = .02), treatment type (P = .04), and recanalization status (P < .01) were independently associated with the 24-hour NIHSS scores. The 24-hour NIHSS score strongly mediated the relationship between treatment type and 90-day mRS (P < .01 for indirect effect when adjusted for age), while posttreatment infarct volume did not (P = .26). CONCLUSIONS Endovascular treatment saves brain and improves 90-day clinical outcomes primarily through a beneficial effect on the 24-hour stroke severity.
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Affiliation(s)
- F S Al-Ajlan
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Neurosciences at King Faisal Specialist Hospital and Research Centre (F.S.A.-A.), Riyadh, Saudi Arabia
| | - A S Al Sultan
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P Minhas
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Z Assis
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M A de Miquel
- Stroke Unit (M.A.d.M.), Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - M Millán
- Stroke Unit (M.M., P.C., A.D.), Department of Neurosciences and Department of Radiology, Hospital Germans Trias, Universitat Autosome de Barcelona, Badalona (Barcelona), Spain
| | - L San Román
- Stroke Unit (L.S.R.), Neurology Department, Hospital Clínic, Barcelona, Spain
| | - A Tomassello
- Stroke Unit (A.T.), Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - A M Demchuk
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - T G Jovin
- Stroke Institute (T.G.J.), Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - P Cuadras
- Stroke Unit (M.M., P.C., A.D.), Department of Neurosciences and Department of Radiology, Hospital Germans Trias, Universitat Autosome de Barcelona, Badalona (Barcelona), Spain
| | - A Dávalos
- Stroke Unit (M.M., P.C., A.D.), Department of Neurosciences and Department of Radiology, Hospital Germans Trias, Universitat Autosome de Barcelona, Badalona (Barcelona), Spain
| | - M Goyal
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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18
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Batchelor C, Pordeli P, d’Esterre CD, Najm M, Al-Ajlan FS, Boesen ME, McDougall C, Hur L, Fainardi E, Shankar JJS, Rubiera M, Khaw AV, Hill MD, Demchuk AM, Sajobi TT, Goyal M, Lee TY, Aviv RI, Menon BK. Use of Noncontrast Computed Tomography and Computed Tomographic Perfusion in Predicting Intracerebral Hemorrhage After Intravenous Alteplase Therapy. Stroke 2017; 48:1548-1553. [DOI: 10.1161/strokeaha.117.016616] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/07/2017] [Accepted: 03/13/2017] [Indexed: 01/25/2023]
Abstract
Background and Purpose—
Intracerebral hemorrhage is a feared complication of intravenous alteplase therapy in patients with acute ischemic stroke. We explore the use of multimodal computed tomography in predicting this complication.
Methods—
All patients were administered intravenous alteplase with/without intra-arterial therapy. An age- and sex-matched case–control design with classic and conditional logistic regression techniques was chosen for analyses. Outcome was parenchymal hemorrhage on 24- to 48-hour imaging. Exposure variables were imaging (noncontrast computed tomography hypoattenuation degree, relative volume of very low cerebral blood volume, relative volume of cerebral blood flow ≤7 mL/min·per 100 g, relative volume of T
max
≥16 s with all volumes standardized to
z
axis coverage, mean permeability surface area product values within T
max
≥8 s volume, and mean permeability surface area product values within ipsilesional hemisphere) and clinical variables (NIHSS [National Institutes of Health Stroke Scale], onset to imaging time, baseline systolic blood pressure, blood glucose, serum creatinine, treatment type, and reperfusion status).
Results—
One-hundred eighteen subjects (22 patients with parenchymal hemorrhage versus 96 without, median baseline NIHSS score of 15) were included in the final analysis. In multivariable regression, noncontrast computed tomography hypoattenuation grade (
P
<0.006) and computerized tomography perfusion white matter relative volume of very low cerebral blood volume (
P
=0.04) were the only significant variables associated with parenchymal hemorrhage on follow-up imaging (area under the curve, 0.73; 95% confidence interval, 0.63–0.83). Interrater reliability for noncontrast computed tomography hypoattenuation grade was moderate (κ=0.6).
Conclusions—
Baseline hypoattenuation on noncontrast computed tomography and very low cerebral blood volume on computerized tomography perfusion are associated with development of parenchymal hemorrhage in patients with acute ischemic stroke receiving intravenous alteplase.
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19
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Al-Ajlan FS, Demchuk AM, Aviv RI, Rodriguez-Luna D, Molina C, Silva Y, Dzialowski I, Czlonkowska A A, Boulanger JM, Lum C, Gubitz G, Padma V, Roy J, Kase CS, Hill MD, Dowlatshahi D. Abstract WP372: The Acute ICH Growth Score: Simple and Accurate Predictor of Hematoma Expansion in Patients with Acute Intracerebral Hemorrhage. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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 and Purpose:
Acute intracerebral hemorrhage (ICH) hematoma expansion predicts high mortality and morbidity, occurring in a third of patients presenting with this condition. Recent studies correlated ultra-early hematoma growth and hematoma morphologic appearance with ICH expansion. Our purpose was to develop simple and clinically useful score that would predict ICH hematoma expansion accurately.
Methods:
This cohort included patients with primary or anticoagulation-associated ICH patients presenting <6 hours post ictus prospectively enrolled in the PREDICT study. Patients underwent baseline CT, CT angiography and 24-hour CT for hematoma expansion analysis. A risk score model was developed for predicting hematoma expansion (> 6 ml or > 33%). A 7-point acute ICH growth score was based on ultra-early hematoma growth > 5 mL/hour (yes=1), irregular morphology (yes=1), density heterogeneity (yes=1), presence of fluid-blood levels (yes=1), spot sign (yes=1), and use of anticoagulation (yes=2). Discrimination of the expansion score was assessed.
Results:
We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients. The 7-point acute ICH growth score demonstrated good discrimination for hematoma expansion>6 mL or 33% (area under the curve of 0.76). Median and significant HE are shown in the table below (p<0.001).
Conclusions:
In a multicenter prospective study, the ICH expansion score demonstrate good correlation with hematoma expansion, and included recently reported variables such as morphology and ultraearly growth.
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Affiliation(s)
- F S Al-Ajlan
- Ottawa Stroke Program, Univ of Ottawa, Ottawa, Canada
| | - A M Demchuk
- Calgary Stroke Program, Univ of Calgary, Calgary, Canada
| | - R I Aviv
- Med Imaging, Univ of Toronto, Toronto, Canada
| | - D Rodriguez-Luna
- Dept of Neurology, Vall d’Hebron Univ Hosp and Vall d’Hebron Rsch Institute, Barcelona, Spain, barcelona, Spain
| | - C Molina
- Calgary Stroke Program, Dept of Neurology, Vall d’Hebron Univ Hosp, Vall d’Hebron Rsch Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain., barcelona, Spain
| | - Y Silva
- Dept of Neurology, Dr Josep Trueta Univ Hosp, Institut d’Investigació Biomèdica Girona, Girona, Spain
| | - I Dzialowski
- Dept of Neurology, Elblandklinikum Meissen Academic Teaching Hosp of the Technische Univ, Dresden, Germany., Dresden, Germany
| | - A Czlonkowska A
- 2nd Dept of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland Dept of Experimental and Clinical Pharmacology, Med Univ of Warsaw, Warsaw, Poland, Warsaw, Poland
| | - J M Boulanger
- Dept of Medicine, Charles LeMoyne Hosp, Univ of Sherbrooke, Montreal, Canada., Montreal, Canada
| | - C Lum
- Dept of Diagnostic Imaging, Neuroradiology Section, Univ of Ottawa, Ottawa Hosp Rsch Institute, Ottawa, Canada., Ottawa, Canada
| | - G Gubitz
- Dept of Neurology, Dalhousie Univ, Halifax, Canada., Halifax, Canada
| | - V Padma
- Ottawa Stroke Program, Dept of Neurology, All India Institute of Med Sciences,, New Delhi, India
| | - J Roy
- AMRI Neurosciences Cntr, Mukundapurz, ,, Kolkata, Canada
| | - C S Kase
- Dept of Neurology, Boston Med Cntr, Boston, USA., Boston, MA
| | - M D Hill
- Calgary Stroke Program, Dept of Clinical Neurosciences, Hotchkiss Brain Institute,, Calgary, Canada
| | - D Dowlatshahi
- Dept of Medicine (Neurology), Univ of Ottawa and Ottawa Hosp Rsch Institute, Ottawa, Canada., Ottawa, Canada
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20
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Ganesh A, Al-Ajlan FS, Sabiq F, Assis Z, Rempel JL, Butcher K, Thornton J, Kelly P, Roy D, Poppe AY, Jovin TG, Devlin T, Baxter BW, Krings T, Casaubon LK, Frei DF, Choe H, Tampieri D, Teitelbaum J, Lum C, Mandzia J, Phillips SJ, Bang OY, Almekhlafi MA, Coutts SB, Barber PA, Sajobi T, Demchuk AM, Eesa M, Hill MD, Goyal M, Menon BK. Infarct in a New Territory After Treatment Administration in the ESCAPE Randomized Controlled Trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times). Stroke 2016; 47:2993-2998. [DOI: 10.1161/strokeaha.116.014852] [Citation(s) in RCA: 42] [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] [Received: 07/30/2016] [Revised: 09/06/2016] [Accepted: 09/30/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Infarct in a new previously unaffected territory (INT) is a potential complication of endovascular treatment. We applied a recently proposed methodology to identify and classify INTs in the ESCAPE randomized controlled trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times).
Methods—
The core laboratory identified INTs on 24-hour follow-up imaging, blinded to treatment allocation, after assessing all baseline imaging. INTs were classified into 3 types (I–III) and 2 subtypes (A/B) based on size and if catheter manipulation was likely performed across the vessel territory ostium. Logistic regression was used to understand the effect of multiple a priori identified variables on INT occurrence. Ordinal logistic regression was used to analyze the effect of INTs on modified Rankin Scale shift at 90 days.
Results—
From 308 patients included, 14 INTs (4.5% overall; 2.8% on follow-up noncontrast computed tomography, 11.7% on follow-up magnetic resonance imaging) were identified (5.0% in endovascular treatment arm versus 4.0% in control arm [
P
=0.7]). The use of intravenous alteplase was associated with a 68% reduction in the odds of INT occurrence (3.0% with versus 9.1% without; odds ratio, 0.32; 95% confidence interval, 0.11–0.96; adjusted for age, sex, and treatment type). No other variables were associated with INTs. INT occurrence was associated with reduced probability of good clinical outcome (common odds ratio, 0.25; 95% confidence interval, 0.09–0.74; adjusted for age, type of treatment, and follow-up scan).
Conclusions—
INTs are uncommon, detected more frequently on follow-up magnetic resonance imaging, and affect clinical outcome. In experienced centers, endovascular treatment is likely not causal, whereas intravenous alteplase may be therapeutic.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01778335.
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Affiliation(s)
- Aravind Ganesh
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Fahad S. Al-Ajlan
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Farahna Sabiq
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Zarina Assis
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Jeremy L. Rempel
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Kenneth Butcher
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - John Thornton
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Peter Kelly
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Daniel Roy
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Alexandre Y. Poppe
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Tudor G. Jovin
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Thomas Devlin
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Blaise W. Baxter
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Timo Krings
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Leanne K. Casaubon
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Donald F. Frei
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Hana Choe
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Donatella Tampieri
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Jeanne Teitelbaum
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Cheemun Lum
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Jennifer Mandzia
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Stephen J. Phillips
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Oh Young Bang
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Mohammed A. Almekhlafi
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Shelagh B. Coutts
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Philip A. Barber
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Tolulope Sajobi
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Andrew M. Demchuk
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Muneer Eesa
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Michael D. Hill
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Mayank Goyal
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
| | - Bijoy K. Menon
- From the Departments of Clinical Neurosciences and Radiology (A.G., F.S.A.-A., F.S., Z.A., S.B.C., P.A.B., A.M.D., M.E., M.D.H., M.G., B.K.M.), Departments of Community Health Sciences and Medicine (S.B.C., T.S., M.D.H., B.K.M.), and Hotchkiss Brain Institute (S.B.C., P.A.B., A.M.D., M.D.H., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Neuroradiology (T.K.), and Division of Neurology, Department of Medicine (L.K.C.), UHN, Toronto Western Hospital,
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Al-Ajlan FS, Goyal M, Demchuk AM, Minhas P, Sabiq F, Assis Z, Willinsky R, Montanera WJ, Rempel JL, Shuaib A, Thornton J, Williams D, Roy D, Poppe AY, Jovin TG, Sapkota BL, Baxter BW, Krings T, Silver FL, Frei DF, Fanale C, Tampieri D, Teitelbaum J, Lum C, Dowlatshahi D, Shankar JJ, Barber PA, Hill MD, Menon BK. Intra-Arterial Therapy and Post-Treatment Infarct Volumes: Insights From the ESCAPE Randomized Controlled Trial. Stroke 2016; 47:777-81. [PMID: 26892284 DOI: 10.1161/strokeaha.115.012424] [Citation(s) in RCA: 48] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The goal of reperfusion therapy in acute ischemic stroke is to limit brain infarction. The objective of this study was to investigate whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in post-treatment infarct volume. METHODS The Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 315 enrolled subjects (endovascular treatment n=165; control n=150), 314 subject's infarct volumes at 24 to 48 hours on magnetic resonance imaging (n=254) or computed tomography (n=60) were measured. Post-treatment infarct volumes were compared by treatment assignment and recanalization/reperfusion status. Appropriate statistical models were used to assess relationship between baseline clinical and imaging variables, post-treatment infarct volume, and functional status at 90 days (modified Rankin Scale). RESULTS Median post-treatment infarct volume in all subjects was 21 mL (interquartile range =65 mL), in the intervention arm, 15.5 mL (interquartile range =41.5 mL), and in the control arm, 33.5 mL (interquartile range =84 mL; P<0.01). Baseline National Institute of Health Stroke Scale (P<0.01), site of occlusion (P<0.01), baseline noncontrast computed tomographic scan Alberta Stroke Program Early CT score (ASPECTS) (P<0.01), and recanalization (P<0.01) were independently associated with post-treatment infarct volume, whereas age, sex, treatment type, intravenous alteplase, and time from onset to randomization were not (P>0.05). Post-treatment infarct volume (P<0.01) and delta National Institute of Health Stroke Scale (P<0.01) were independently associated with 90-day modified Rankin Scale, whereas laterality (left versus right) was not. CONCLUSIONS These results support the primary results of the ESCAPE trial and show that the biological underpinning of the success of endovascular therapy is a reduction in infarct volume. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01778335.
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Affiliation(s)
- Fahad S Al-Ajlan
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Mayank Goyal
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Andrew M Demchuk
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Priyanka Minhas
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Farahna Sabiq
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Zarina Assis
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Robert Willinsky
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Walter J Montanera
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Jeremy L Rempel
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Ashfaq Shuaib
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - John Thornton
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - David Williams
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Daniel Roy
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Alexandre Y Poppe
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Tudor G Jovin
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Biggya L Sapkota
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Blaise W Baxter
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Timo Krings
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Frank L Silver
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Donald F Frei
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Christopher Fanale
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Donatella Tampieri
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Jeanne Teitelbaum
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Cheemun Lum
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Dar Dowlatshahi
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Jai J Shankar
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Philip A Barber
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Michael D Hill
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.)
| | - Bijoy K Menon
- From the Department of Clinical Neurosciences and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary (F.S.A.-A., M.G., A.M.D., P.M., F.S., Z.A., P.A.B., M.D.H., B.K.M.); Department of Community Health Sciences and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary (M.D.H., B.K.M.); Department of Medical Imaging, UHN, Toronto Western Hospital, Toronto (R.W., W.J.M.); Department of Surgery (Neurosurgery), University of Alberta, Edmonton (J.L.R.); Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.); Department of Neuroradiology, Beaumont Hospital and the Royal College of Surgeons in Ireland (J. Thornton); Department of Geriatric and Stroke Medicine, Beaumont Hospital and the Royal College of Surgeons in Ireland (D.W.); Department of Radiology, CHUM, University of Montreal, Montreal (D.R.); Department of Neurosciences, CHUM, University of Montreal, Montreal (A.Y.P.); Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Division of Neurology, University of Tennessee, Chattanooga (B.L.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology, UHN, Toronto Western Hospital, Toronto (T.K.); Division of Neurology, Department of Medicine, UHN, Toronto Western Hospital, Toronto (F.L.S., C.F.); Colorado Neurological Institute, Engelwood (D.F.F., D.T.); Montreal Neurological Institute, McGill University, Montreal (J. Teitelbaum); Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa (C.L.); Department of Neurology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.D.); Department of Neuroradiology, Dalhousie University, Halifax (J.J.S.); and Hotchkiss Brain Institute, University of Calgary (M.G., A.M.D., P.A.B., M.D.H., B.K.M.).
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22
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Klourfeld E, Zerna C, Al-Ajlan FS, Kamal N, Randhawa P, Yu AY, Dowlatshahi D, Thornton J, Williams D, Holmstedt C, Kelly M, Frei D, Baxter B, Linares G, Bang OY, Poppe AY, Montanera W, Rempel J, Eesa M, Menon BK, Demchuk AM, Goyal M, Hill MD. The future of endovascular treatment: Insights from the ESCAPE investigators. Int J Stroke 2016; 11:156-63. [PMID: 26783306 DOI: 10.1177/1747493015622962] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The ESCAPE trial demonstrated strong morbidity benefit and mortality reduction for endovascular stroke treatment. Following the release of the main results, the ESCAPE trial investigators convened at a 2-day close-out meeting in March 2015 in Banff, Alberta, Canada. Meeting discussions focused on system implications, procedural characteristics, and future directions. We report the proceedings of the meeting, which provide insights from the trialists into the issues of generalizability, treatment limitations, as well as future directions and opportunities in stroke care optimization.
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Affiliation(s)
- Evgenia Klourfeld
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Charlotte Zerna
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Fahad S Al-Ajlan
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Noreen Kamal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Privia Randhawa
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Amy Y Yu
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), the Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | | | - David Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland
| | | | - Michael Kelly
- Royal Saskatchewan Hospital, University of Saskatchewan, Saskatoon, SK, Canada
| | - Donald Frei
- Swedish Medical Center, Colorado Neurological Institute, Denver, CO, USA
| | - Blaise Baxter
- Department of Neurology, Erlanger Hospital, Chattanooga, TN, USA
| | - Guillermo Linares
- Departments of Neurology, Neurosurgery and Radiology, Temple University, Philadelphia, PA, USA
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Seoul, Korea
| | - Alexandre Y Poppe
- Department of Neurosciences, Université de Montréal, Montréal, QC, Canada
| | - Walter Montanera
- Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - Jeremy Rempel
- Department of Radiology, University of Alberta, Edmonton, AB, Canada
| | - Muneer Eesa
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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