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Hernandez-Duran S, Walter J, Behmanesh B, Bernstock JD, Czabanka M, Dinc N, Dubinski D, Freiman TM, Günther A, Hellmuth K, Herrmann E, Konczalla J, Maier I, Melkonian R, Mielke D, Müller SJ, Naser P, Rohde V, Schaefer JH, Senft C, Storch A, Unterberg A, Walter U, Wittstock M, Gessler F, Won SY. Necrosectomy Versus Stand-Alone Suboccipital Decompressive Craniectomy for the Management of Space-Occupying Cerebellar Infarctions-A Retrospective Multicenter Study. Neurosurgery 2024; 94:559-566. [PMID: 37800900 DOI: 10.1227/neu.0000000000002707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/08/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Space-occupying cerebellar stroke (SOCS) when coupled with neurological deterioration represents a neurosurgical emergency. Although current evidence supports surgical intervention in such patients with SOCS and rapid neurological deterioration, the optimal surgical methods/techniques to be applied remain a matter of debate. METHODS We conducted a retrospective, multicenter study of patients undergoing surgery for SOCS. Patients were stratified according to the type of surgery as (1) suboccipital decompressive craniectomy (SDC) or (2) suboccipital craniotomy with concurrent necrosectomy. The primary end point examined was functional outcome using the modified Rankin Scale (mRS) at discharge and at 3 months (mRS 0-3 defined as favorable and mRS 4-6 as unfavorable outcome). Secondary end points included the analysis of in-house postoperative complications, mortality, and length of hospitalization. RESULTS Ninety-two patients were included in the final analysis: 49 underwent necrosectomy and 43 underwent SDC. Those with necrosectomy displayed significantly higher rate of favorable outcome at discharge as compared with those who underwent SDC alone: 65.3% vs 27.9%, respectively ( P < .001, odds ratios 4.9, 95% CI 2.0-11.8). This difference was also observed at 3 months: 65.3% vs 41.7% ( P = .030, odds ratios 2.7, 95% CI 1.1-6.7). No significant differences were observed in mortality and/or postoperative complications, such as hemorrhagic transformation, infection, and/or the development of cerebrospinal fluid leaks/fistulas. CONCLUSION In the setting of SOCS, patients treated with necrosectomy displayed better functional outcomes than those patients who underwent SDC alone. Ultimately, prospective, randomized studies will be needed to confirm this finding.
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Affiliation(s)
| | - Johannes Walter
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Marcus Czabanka
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main , Germany
| | - Nazife Dinc
- Department of Neurosurgery, Jena University Hospital, Jena , Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena , Germany
| | - Kara Hellmuth
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt am Main , Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main , Germany
| | - Ilko Maier
- Department of Neurology, Göttingen University Hospital, Göttingen , Germany
| | | | - Dorothee Mielke
- Department of Neurosurgery, Göttingen University Hospital, Göttingen , Germany
| | - Sebastian Johannes Müller
- Department of Neuroradiology, Göttingen University Hospital, Göttingen , Germany
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart , Germany
| | - Paul Naser
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Veit Rohde
- Department of Neurosurgery, Göttingen University Hospital, Göttingen , Germany
| | - Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main , Germany
| | - Christian Senft
- Department of Neurosurgery, Jena University Hospital, Jena , Germany
| | - Alexander Storch
- Department of Neurology, University Medicine Rostock, Rostock , Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Uwe Walter
- Department of Neurology, University Medicine Rostock, Rostock , Germany
| | | | - Florian Gessler
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
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2
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Won SY, Hernández-Durán S, Behmanesh B, Bernstock JD, Czabanka M, Dinc N, Dubinski D, Freiman TM, Günther A, Hellmuth K, Herrmann E, Konczalla J, Maier I, Melkonian R, Mielke D, Naser P, Rohde V, Senft C, Storch A, Unterberg A, Walter J, Walter U, Wittstock M, Schaefer JH, Gessler F. Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts. JAMA Neurol 2024:2815568. [PMID: 38407889 PMCID: PMC10897822 DOI: 10.1001/jamaneurol.2023.5773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/21/2023] [Indexed: 02/27/2024]
Abstract
Importance According to the current American Heart Association/American Stroke Association guidelines, decompressive surgery is indicated in patients with cerebellar infarcts that demonstrate severe cerebellar swelling. However, there is no universal definition of swelling and/or infarct volume(s) available to support a decision for surgery. Objective To evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts. Design, Setting, and Participants In this retrospective multicenter cohort study, patients with cerebellar infarcts treated at 5 tertiary referral hospitals or stroke centers within Germany between 2008 and 2021 were included. Data were analyzed from November 2020 to November 2023. Exposures Surgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care). Main Outcomes and Measures The primary outcome examined was functional status evaluated by the modified Rankin Scale (mRS) at discharge and 1-year follow-up. Secondary outcomes included the predicted probabilities for favorable outcome (mRS score of 0 to 3) stratified by infarct volumes or Glasgow Coma Scale score at admission and treatment modality. Analyses included propensity score matching, with adjustments for age, sex, Glasgow Coma Scale score at admission, brainstem involvement, and infarct volume. Results Of 531 included patients with cerebellar infarcts, 301 (57%) were male, and the mean (SD) age was 68 (14.4) years. After propensity score matching, a total of 71 patients received surgical treatment and 71 patients conservative treatment. There was no significant difference in favorable outcomes (ie, mRS score of 0 to 3) at discharge for those treated surgically vs conservatively (47 [66%] vs 45 [65%]; odds ratio, 1.1; 95% CI, 0.5-2.2; P > .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P > .99). In patients with cerebellar infarct volumes of 35 mL or greater, surgical treatment was associated with a significant improvement in favorable outcomes at 1-year follow-up (38 [61%] vs 3 [25%]; odds ratio, 4.8; 95% CI, 1.2-19.3; P = .03), while conservative treatment was associated with favorable outcomes at 1-year follow-up in patients with infarct volumes of less than 25 mL (2 [34%] vs 218 [74%]; odds ratio, 0.2; 95% CI, 0-1.0; P = .047). Conclusions and Relevance Overall, surgery was not associated with improved outcomes compared with conservative management in patients with cerebellar infarcts. However, when stratifying based on infarct volume, surgical treatment appeared to be beneficial in patients with larger infarct volumes, while conservative management appeared favorable in patients with smaller infarct volumes.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | | | - Bedjan Behmanesh
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Nazife Dinc
- Department of Neurosurgery, Jena University Hospital, Jena, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Thomas M. Freiman
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Kara Hellmuth
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Ilko Maier
- Department of Neurology, Göttingen University Hospital, Göttingen, Germany
| | | | - Dorothee Mielke
- Department of Neurosurgery, Göttingen University Hospital, Göttingen, Germany
| | - Paul Naser
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Veit Rohde
- Department of Neurosurgery, Göttingen University Hospital, Göttingen, Germany
| | - Christian Senft
- Department of Neurosurgery, Jena University Hospital, Jena, Germany
| | - Alexander Storch
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Johannes Walter
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Uwe Walter
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Matthias Wittstock
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Jan Hendrik Schaefer
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
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3
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Silva MA, Elawady SS, Maier I, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Psychogios MN, Samaniego EA, Goyal N, Yoshimura S, Cuellar H, Grossberg JA, Alawieh A, Alaraj A, Ezzeldin M, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka AJ, Siddiqui FM, Osbun JW, Crosa RJ, Matouk C, Levitt MR, Brinjikji W, Moss M, Dumont TM, Williamson R, Navia P, Kan P, De Leacy RA, Chowdhry SA, Spiotta AM, Park MS, Starke RM. Comparison between transradial and transfemoral mechanical thrombectomy for ICA and M1 occlusions: insights from the Stroke Thrombectomy and Aneurysm Registry (STAR). J Neurointerv Surg 2024:jnis-2023-021358. [PMID: 38388480 DOI: 10.1136/jnis-2023-021358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/12/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND The role for the transradial approach for mechanical thrombectomy is controversial. We sought to compare transradial and transfemoral mechanical thrombectomy in a large multicenter database of acute ischemic stroke. METHODS The prospectively maintained Stroke Thrombectomy and Aneurysm Registry (STAR) was reviewed for patients who underwent mechanical thrombectomy for an internal carotid artery (ICA) or middle cerebral artery M1 occlusion. Multivariate regression analyses were performed to assess outcomes including reperfusion time, symptomatic intracerebral hemorrhage (ICH), distal embolization, and functional outcomes. RESULTS A total of 2258 cases, 1976 via the transfemoral approach and 282 via the transradial approach, were included. Radial access was associated with shorter reperfusion time (34.1 min vs 43.6 min, P=0.001) with similar rates of Thrombolysis in Cerebral Infarction (TICI) 2B or greater reperfusion (87.9% vs 88.1%, P=0.246). Patients treated via a transradial approach were more likely to achieve at least TICI 2C (59.6% vs 54.7%, P=0.001) and TICI 3 reperfusion (50.0% vs 46.2%, P=0.001), and had shorter lengths of stay (mean 9.2 days vs 10.2, P<0.001). Patients treated transradially had a lower rate of symptomatic ICH (8.0% vs 9.4%, P=0.047) but a higher rate of distal embolization (23.0% vs 7.1%, P<0.001). There were no significant differences in functional outcome at 90 days between the two groups. CONCLUSIONS Radial and femoral thrombectomy resulted in similar clinical outcomes. In multivariate analysis, the radial approach had improved revascularization rates, fewer cases of symptomatic ICH, and faster reperfusion times, but higher rates of distal emboli. Further studies on the optimal approach are necessary based on patient and disease characteristics.
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Affiliation(s)
- Michael A Silva
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sameh Samir Elawady
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Edgar A Samaniego
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Nitin Goyal
- Neurology, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hugo Cuellar
- Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
| | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alaraj
- Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, HCA Houston Healthcare Kingwood, University of Houston, Kingswood, Texas, USA
| | - Daniele G Romano
- Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Justin Mascitelli
- Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Fazeel M Siddiqui
- Department of Neuroscience, University of Michigan Health-West, Wyoming, Michigan, USA
| | - Joshua W Osbun
- Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | | | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Mark Moss
- Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | - Travis M Dumont
- Department of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | | | - Pedro Navia
- Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | | | - Shakeel A Chowdhry
- Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Min S Park
- Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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4
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Orscelik A, Matsukawa H, Elawady SS, Sowlat MM, Cunningham C, Zandpazandi S, Kasem RA, Maier I, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Shaban A, Goyal N, Yoshimura S, Cuellar H, Howard B, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka A, Osbun J, Crosa R, Matouk C, Park MS, Levitt MR, Brinjikji W, Moss M, Dumont T, Williamson R, Navia P, Kan P, De Leacy R, Chowdhry S, Ezzeldin M, Spiotta AM, Kasab SA. Comparative Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Patients with ASPECTS 2-3 vs. 4-5. J Stroke Cerebrovasc Dis 2024; 33:107528. [PMID: 38134550 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND The influence of Alberta Stroke Program Early CT Score (ASPECTS) on outcomes following mechanical thrombectomy (MT) for acute ischemic stroke (AIS) patients with low ASPECTS remains unknown. In this study, we compared the outcomes of AIS patients treated with MT for large vessel occlusion (LVO) categorized by ASPECTS value. METHODS We conducted a retrospective analysis involving 305 patients with AIS caused by LVO, defined as the occlusion of the internal carotid artery and/or the M1 segments of the middle cerebral artery, stratified into two groups: ASPECTS 2-3 and 4-5. The primary outcome was favorable outcome defined as a 90-day modified Rankin Scale (mRS) score of 0-3. Secondary outcomes were 90-day mRS 0-2, 90-day mortality, any intracerebral hemorrhage (ICH), and symptomatic ICH (sICH). We performed multivariable logistic regression analysis to evaluate the impact of ASPECTS 2-3 vs. 4-5 on outcomes. RESULTS Fifty-nine patients (19.3%) had ASPECTS 2-3 and 246 (80.7%) had ASPECTS 4-5. Favorable outcomes showed no significant difference between the two groups (adjusted odds ratio [aOR]= 1.13, 95% confidence interval [CI]: 0.52-2.41, p=0.80). There were also no significant differences in 90-day mRS 0-2 (aOR= 1.65, 95% CI: 0.66-3.99, p=0.30), 90-day mortality (aOR= 1.14, 95% CI: 0.58-2.20, p=0.70), any ICH (aOR= 0.54, 95% CI: 0.28-1.00, p=0.06), and sICH (aOR= 0.70, 95% CI: 0.27-1.63, p = 0.40) between the groups. CONCLUSIONS AIS patients with LVO undergoing MT with ASPECTS 2-3 had similar outcomes compared to ASPECTS 4-5.
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Affiliation(s)
- Atakan Orscelik
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA; Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Mohamed Mahdi Sowlat
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Sara Zandpazandi
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Rahim Abo Kasem
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, Germany.
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea.
| | | | - Ansaar Rai
- Department of Radiology, West Virginia University, Morgantown, WV, USA.
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University of Basel, Basel, Switzerland.
| | - Amir Shaban
- Department of Neurology, University of Iowa, Iowa City, IA, USA.
| | - Nitin Goyal
- Department of Neurosurgery, University of Tennessee Health Science Center/Semmes-Murphey Foundation, Memphis, TN, USA.
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health, Shreveport, LA, USA.
| | - Brian Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Daniele G Romano
- Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Salerno, Italy.
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisboa, Portugal.
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University in St. Louis, St. Louis, MO, USA.
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Medica Uruguaya, Montevideo, Uruguay.
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, WA, USA.
| | | | - Mark Moss
- Department of Neuroradiology, Washington Regional Medical Center, Fayetteville, AZ, USA.
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tucson, AZ, USA.
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA, USA.
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX, USA.
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Shakeel Chowdhry
- Department of Neurosurgery, NorthShore University Health System, Chicago, IL, USA.
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, University of Houston, HCA Houston Healthcare Kingwood, Houston, TX, USA.
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
| | - Sami Al Kasab
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA.
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5
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Elawady SS, Saway BF, Matsukawa H, Uchida K, Lin S, Maier I, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur A, Yoshimura S, Cuellar H, Grossberg JA, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka A, Osbun J, Crosa R, Matouk C, Park MS, Levitt MR, Brinjikji W, Moss M, Dumont T, Williamson R, Navia P, Kan P, Leacy RD, Chowdhry S, Ezzeldin M, Spiotta AM, Kasab SA. Thrombectomy in Stroke Patients With Low Alberta Stroke Program Early Computed Tomography Score: Is Modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3 Superior to mTICI 2b? J Stroke 2024; 26:95-103. [PMID: 38326708 PMCID: PMC10850454 DOI: 10.5853/jos.2023.02292] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/13/2023] [Accepted: 10/04/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND AND PURPOSE Outcomes following mechanical thrombectomy (MT) are strongly correlated with successful recanalization, traditionally defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b. This retrospective cohort study aimed to compare the outcomes of patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS; 2-5) who achieved mTICI 2b versus those who achieved mTICI 2c/3 after MT. METHODS This study utilized data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combined databases from 32 thrombectomy-capable stroke centers between 2013 and 2023. The study included only patients with low ASPECTS who achieved mTICI 2b, 2c, or 3 after MT for internal carotid artery or middle cerebral artery (M1) stroke. RESULTS Of the 10,229 patients who underwent MT, 234 met the inclusion criteria. Of those, 98 (41.9%) achieved mTICI 2b, and 136 (58.1%) achieved mTICI 2c/3. There were no significant differences in baseline characteristics between the two groups. The 90-day favorable outcome (modified Rankin Scale score: 0-3) was significantly better in the mTICI 2c/3 group than in the mTICI 2b group (adjusted odds ratio 2.35; 95% confidence interval [CI] 1.18-4.81; P=0.02). Binomial logistic regression revealed that achieving mTICI 2c/3 was significantly associated with higher odds of a favorable 90-day outcome (odds ratio 2.14; 95% CI 1.07-4.41; P=0.04). CONCLUSION In patients with low ASPECTS, achieving an mTICI 2c/3 score after MT is associated with a more favorable 90-day outcome. These findings suggest that mTICI 2c/3 is a better target for MT than mTICI 2b in patients with low ASPECTS.
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Affiliation(s)
- Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Brian Fabian Saway
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Steven Lin
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | | | - Ansaar Rai
- Department of Radiology, West Virginia School of Medicine, Morgantown, WV, USA
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
| | - Marios-Nikos Psychogios
- Department of Interventional and Diagnostical Neuroradiology, University of Basel, Basel, Switzerland
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Adam Arthur
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hugo Cuellar
- Department of Neurosurgery and Neurointerventional Radiology, Louisiana State University, Shreveport, LA, USA
| | - Jonathan A. Grossberg
- Department of Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Ali Alawieh
- Department of Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Daniele G. Romano
- Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Isabel Fragata
- Department of Neuroradiology, Hospital São José Centro Hospitalar, Lisboa, Portugal
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Min S. Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Michael R. Levitt
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Mark Moss
- Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, AZ, USA
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tucson, AZ, USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurological Surgery, University of Texas Medical Branch - Galveston, TX, USA
| | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Shakeel Chowdhry
- Department of Neurosurgery, NorthShore University Health System, Evanston, IL, USA
| | - Mohamad Ezzeldin
- University of Houston, Department of Clinical Neuroscience, HCA Houston Healthcare Kingwood, Houston, TX, USA
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sami Al Kasab
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - on behalf of the STAR Collaborators
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Department of Radiology, West Virginia School of Medicine, Morgantown, WV, USA
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
- Department of Interventional and Diagnostical Neuroradiology, University of Basel, Basel, Switzerland
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Neurosurgery and Neurointerventional Radiology, Louisiana State University, Shreveport, LA, USA
- Department of Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Salerno, Italy
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Department of Neuroradiology, Hospital São José Centro Hospitalar, Lisboa, Portugal
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
- Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, AZ, USA
- Department of Neurosurgery, University of Arizona, Tucson, AZ, USA
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA, USA
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
- Department of Neurological Surgery, University of Texas Medical Branch - Galveston, TX, USA
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
- Department of Neurosurgery, NorthShore University Health System, Evanston, IL, USA
- University of Houston, Department of Clinical Neuroscience, HCA Houston Healthcare Kingwood, Houston, TX, USA
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6
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Anadani M, Almallouhi E, Maier I, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Cuellar H, Howard BM, Alawieh A, Fragata I, Polifka AJ, Mascitelli JR, Osbun JW, Matouk C, Park MS, Levitt MR, Dumont TM, Williamson R, Spiotta AM. Effect of intravenous thrombolysis before endovascular therapy on outcomes in patients with large core infarct. J Neurointerv Surg 2023; 15:e414-e418. [PMID: 36990690 DOI: 10.1136/jnis-2022-019537] [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: 08/16/2022] [Accepted: 02/17/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND The safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone. METHODS This is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups. RESULTS A total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0-2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes. CONCLUSION Pretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.
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Affiliation(s)
- Mohammad Anadani
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Sami Al Kasab
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Edgar A Samaniego
- Neurology, Radiology and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hugo Cuellar
- Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Joshua W Osbun
- Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Min S Park
- Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | | | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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7
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Shaban A, Al Kasab S, Chalhoub RM, Bass E, Maier I, Psychogios MN, Alawieh A, Wolfe SQ, Arthur AS, Dumont TM, Kan P, Kim JT, De Leacy R, Osbun JW, Rai AT, Jabbour P, Park MS, Crosa RJ, Mascitelli JR, Levitt MR, Polifka AJ, Casagrande W, Yoshimura S, Matouk C, Williamson R, Gory B, Mokin M, Fragata I, Romano DG, Chowdhry SA, Moss M, Behme D, Limaye K, Spiotta AM, Samaniego EA. Mechanical thrombectomy for large vessel occlusion strokes beyond 24 hours. J Neurointerv Surg 2023; 15:e331-e336. [PMID: 36593118 DOI: 10.1136/jnis-2022-019372] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 08/29/2022] [Accepted: 12/08/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Recent clinical trials have shown that mechanical thrombectomy is superior to medical management for large vessel occlusion for up to 24 hours from onset. Our objective is to examine the safety and efficacy of thrombectomy beyond the standard of care window. METHODS A retrospective review was undertaken of the multicenter Stroke Thrombectomy and Aneurysm Registry (STAR). We identified patients who underwent mechanical thrombectomy for large vessel occlusion beyond 24 hours. We selected a matched control group from patients who underwent thrombectomy in the 6-24-hour window. We used functional independence at 3 months as our primary outcome measure. RESULTS We identified 121 patients who underwent thrombectomy beyond 24 hours and 1824 in the 6-24-hour window. We selected a 2:1 matched group of patients with thrombectomy 6-24 hours as a comparison group. Patients undergoing thrombectomy beyond 24 hours were less likely to be independent at 90 days (18 (18.8%) vs 73 (34.9%), P=0.005). They had higher odds of mortality at 90 days in the adjusted analysis (OR 2.34, P=0.023). Symptomatic intracerebral hemorrhage and other complications were similar in the two groups. In a multivariate analysis only lower number of attempts was associated with good outcomes (OR 0.27, P=0.022). CONCLUSIONS Mechanical thrombectomy beyond 24 hours appears to be safe and tolerable with no more hemorrhages or complications compared with standard of care thrombectomy. Outcomes and mortality in this time window are worse compared with an earlier time window, but the rates of good outcomes may justify this therapy in selected patients.
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Affiliation(s)
- Amir Shaban
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Reda M Chalhoub
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eric Bass
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Ali Alawieh
- Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Seol, Korea (the Republic of)
| | - Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
| | - Joshua W Osbun
- Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ansaar T Rai
- Department of Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Min S Park
- Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | | | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Richard Williamson
- Stroke & Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Maxim Mokin
- Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Daniele G Romano
- Policlinico "Santa Maria alle Scotte", Unit of Neuroimaging and Neurointervention Siena, IT, University Hospital of Siena, Siena, Italy
| | | | - Mark Moss
- Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Kaustubh Limaye
- Neurology, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Edgar A Samaniego
- Neurology, Radiology and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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8
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Almallouhi E, Zandpazandi S, Anadani M, Cunningham C, Sowlat MM, Matsukawa H, Orscelik A, Elawady SS, Maier I, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Cuellar H, Grossberg JA, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka AJ, Osbun JW, Crosa RJ, Matouk C, Park MS, Levitt MR, Brinjikji W, Moss M, Dumont TM, Williamson R, Navia P, Kan P, De Leacy R, Chowdhry SA, Ezzeldin M, Spiotta AM. Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core. J Neurointerv Surg 2023:jnis-2023-021046. [PMID: 38041671 DOI: 10.1136/jnis-2023-021046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/04/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Recent clinical trials have demonstrated that patients with large vessel occlusion (LVO) and large infarction core may still benefit from mechanical thrombectomy (MT). In this study, we evaluate outcomes of MT in LVO patients presenting with extremely large infarction core Alberta Stroke Program Early CT Score (ASPECTS 0-2). METHODS Data from the Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We identified thrombectomy patients presenting with an occlusion in the intracranial internal carotid artery (ICA) or M1 segment of the middle cerebral artery and extremely large infarction core (ASPECTS 0-2). A favorable outcome was defined by achieving a modified Rankin scale of 0-3 at 90 days post-MT. Successful recanalization was defined by achieving a modified Thrombolysis In Cerebral Ischemia (mTICI) score ≥2B. RESULTS We identified 58 patients who presented with ASPECTS 0-2 and underwent MT . Median age was 70.0 (59.0-78.0) years, 45.1% were females, and 202 (36.3%) patients received intravenous tissue plasminogen activator. There was no difference regarding the location of the occlusion (p=0.57). Aspiration thrombectomy was performed in 268 (54.6%) patients and stent retriever was used in 70 (14.3%) patients. In patients presenting with ASPECTS 0-2 the mortality rate was 4.5%, 27.9% had mRS 0-3 at day 90, 66.67% ≥70 years of age had mRS of 5-6 at day 90. On multivariable analysis, age, National Institutes of Health Stroke Scale on admission, and successful recanalization (mTICI ≥2B) were independently associated with favorable outcomes. CONCLUSIONS This multicentered, retrospective cohort study suggests that MT may be beneficial in a select group of patients with ASPECTS 0-2.
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Affiliation(s)
- Eyad Almallouhi
- Neuro Interventional Surgery, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Sara Zandpazandi
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohammad Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Conor Cunningham
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohammad-Mahdi Sowlat
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Atakan Orscelik
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sameh Samir Elawady
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- University of Miami School of Medicine, Miami, Florida, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Edgar A Samaniego
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hugo Cuellar
- Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
| | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Daniele G Romano
- Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | | | - Justin Mascitelli
- Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Joshua W Osbun
- Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | | | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Min S Park
- University of Virginia, Charlottesville, Virginia, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Mark Moss
- Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | | | - Pedro Navia
- Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shakeel A Chowdhry
- Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, University of Houston, HCA Houston Healthcare Kingwood, University of Houston, Houston, Texas, USA
- Neuroendovascular surgery, HCA Houston, Houston, Texas, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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9
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Dabhi N, Kumar JS, Ironside N, Kellogg RT, Sowlat MM, Uchida K, Maier I, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Cuellar H, Howard BM, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka AJ, Osbun JW, Crosa RJ, Matouk C, Levitt MR, Brinjikji W, Moss M, Dumont TM, Williamson R, Navia P, Kan P, De Leacy R, Chowdhry SA, Ezzeldin M, Spiotta AM, Park MS. Mechanical thrombectomy for the treatment of primary and secondary anterior cerebral artery occlusions: insights from STAR. J Neurointerv Surg 2023:jnis-2023-020997. [PMID: 37968114 DOI: 10.1136/jnis-2023-020997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/04/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND The safety and efficacy of mechanical thrombectomy (MT) for the treatment of acute anterior cerebral artery (ACA) occlusions have not clearly been delineated. Outcomes may be impacted based on whether the occlusion is isolated to the ACA (primary ACA occlusion) or occurs in conjunction with other cerebral arteries (secondary). METHODS We performed a retrospective review of the multicenter Stroke Thrombectomy and Aneurysm (STAR) database. All patients with MT-treated primary or secondary ACA occlusions were included. Baseline characteristics, procedural outcomes, complications, and clinical outcomes were collected. Primary and secondary ACA occlusions were compared using the Mann-Whitney U test and Kruskal-Willis test for continuous variables and the χ2 test for categorical variables. RESULTS The study cohort comprised 238 patients with ACA occlusions (49.2% female, median (SD) age 65.6 (16.7) years). The overall rate of successful recanalization was 75%, 90-day good functional outcome was 23%, and 90-day mortality was 35%. There were 44 patients with a primary ACA occlusion and 194 patients with a secondary ACA occlusion. When adjusted for baseline variables, the rates of successful recanalization (68% vs 76%, P=0.27), 90-day good functional outcome (41% vs 19%, P=0.38), and mortality at 90 days (25% vs 38%, P=0.12) did not differ between primary and secondary ACA occlusion groups. CONCLUSION Clinical and procedural outcomes are similar between MT-treated primary and secondary ACA occlusions for select patients. Our findings demonstrate the need for established criteria to determine ideal patient and ACA stroke characteristics amenable to MT treatment.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jeyan Sathia Kumar
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mohammad-Mahdi Sowlat
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kazutaka Uchida
- Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Ilko Maier
- Department of Neurosurgery, University Medicine Goettingen, Goettingen, Germany
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Department of Neurosurgery, Chonnam National University Hospital, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Department of Neurosurgery, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | | | - Edgar A Samaniego
- Department of Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Hugo Cuellar
- Department of Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Daniele G Romano
- Department of Neurosurgery, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Justin Mascitelli
- Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Isabel Fragata
- Department of Neurosurgery, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | | | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Mark Moss
- Department of Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | - Travis M Dumont
- Department of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Pedro Navia
- Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shakeel A Chowdhry
- Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Mohamad Ezzeldin
- Department of Neurosurgery, University of Houston, Houston, Texas, USA
- Neuroendovascular Surgery, HCA Houston, Houston, Texas, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Min S Park
- Department of Neurosurgery, Universitätsspital Basel, Basel, Switzerland
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10
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Orscelik A, Kallmes DF, Bilgin C, Musmar B, Senol YC, Kobeissi H, Elawady SS, Cunningham C, Matsukawa H, Zandpazandi S, Sowlat MM, Maier I, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Cuellar H, Howard BM, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka AJ, Osbun JW, Crosa RJ, Matouk C, Park MS, Levitt MR, Moss M, Dumont TM, Williamson R, Navia P, Kan P, De Leacy R, Chowdhry SA, Ezzeldin M, Spiotta AM, Brinjikji W. Comparison of balloon guide catheter versus non-balloon guide catheter for mechanical thrombectomy in patients with distal medium vessel occlusion. J Neurointerv Surg 2023:jnis-2023-020925. [PMID: 37918906 DOI: 10.1136/jnis-2023-020925] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Several studies have established the safety and efficacy of balloon guide catheters (BGCs) for large vessel occlusions. However, the utility of BGCs remains largely unexplored for distal medium vessel occlusions (DMVOs). In this study, we aim to compare the outcomes of BGC vs. Non-BGC in patients undergoing mechanical thrombectomy (MT) for DMVO. METHOD This retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) encompassed adult patients with acute anterior cerebral artery, posterior cerebral artery, and middle cerebral artery-M2-3-4 occlusions. Procedure times, safety, recanalization, and neurological outcomes were compared between the two groups, with subgroup analysis based on first-line thrombectomy techniques. RESULTS A total of 1508 patients were included, with 231 patients (15.3%) in the BGC group and 1277 patients (84.7%) in the non-BGC group. The BGC group had a lower modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2C (43.2% vs 52.7%, P=0.01), longer time from puncture to intracranial access (15 vs 8 min, P<0.01), and from puncture to final recanalization (97 vs 34 min, P<0.01). In the Solumbra subgroup, the first pass effect (FPE) rate was lower in the BGC group (17.4% vs 30.7%, P=0.03). Regarding clinical outcomes, the BGC group had a lower rate of distal embolization (8.8% vs 14.9%, P=0.03). CONCLUSION Our study found that use of BGC in patients with DMVO was associated with lower mTICI scores, decreased FPE rates, reduced distal embolization, and longer procedure times.
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Affiliation(s)
- Atakan Orscelik
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Basel Musmar
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Yigit Can Senol
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sameh Samir Elawady
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Conor Cunningham
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Sara Zandpazandi
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohammad-Mahdi Sowlat
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center/Semmes Murphey Foundation, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Daniele G Romano
- Department of Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Justin Mascitelli
- Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Mark Moss
- Department of Interventional Neuroradiology, Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Richard Williamson
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Pedro Navia
- Department of Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shakeel A Chowdhry
- Department of Neurosurgery, North Shore University Health System, Evanston, Illinois, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, University of Houston, HCA Houston Healthcare, Kingwood, Texas, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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11
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Saad H, Eshraghi S, Alawieh AM, Akbik F, Cawley CM, Howard BM, Ash M, Hsu A, Pabaney A, Maier I, Al Kasab S, El Naamani K, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Shaban A, Arthur AS, Yoshimura S, Fragata I, Cuellar-Saenz HH, Polifka AJ, Mascitelli J, Osbun JW, Matouk C, Park MS, Levitt MR, Dumont TM, Williamson R, Spiotta AM, Grossberg JA. Technical and clinical outcomes in concurrent multivessel occlusions treated with mechanical thrombectomy: insights from the STAR collaboration. J Neurointerv Surg 2023; 15:1072-1077. [PMID: 36597932 DOI: 10.1136/jnis-2022-019608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/05/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has become the mainstay treatment for large vessel occlusion, with favorable safety and efficacy profile. However, the safety and efficacy of EVT in concurrent multi-territory occlusions (MTVOs) remains unclear. OBJECTIVE To investigate the prevalence, clinical and technical outcomes of concurrent EVT for MTVOs. METHODS Data were included from the Stroke Thrombectomy and Aneurysm Registry (STAR) with 32 stroke centers for EVT performed to treat bilateral anterior or concurrent anterior and posterior circulation occlusions between 2017 and 2021. Patients with MTVO were identified, and propensity score matching was used to compare this group with patients with occlusion in a single arterial territory. RESULTS Of a total of 7723 patients who underwent EVT for acute ischemic stroke, 54 (0.7%) underwent EVT for MTVOs (mean age 69±12.5; female 50%). 28% had bilateral and 72% had anterior and posterior circulations occlusions. The rate of successful recanalization (Thrombolysis in Cerebral Infarction 2b/3), complications, modified Rankin score at 90 days, and mortality was not significantly different between the matched cohorts. Multivariate analysis confirmed that MTVOs were not associated with poor functional outcome, symptomatic intracranial hemorrhage, or longer procedure time. CONCLUSION Compared with EVT for single vessel occlusions, EVT in appropriately selected patients with MTVOs has a similar efficacy and safety profile.
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Affiliation(s)
- Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sheila Eshraghi
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali M Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Feras Akbik
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Makenna Ash
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alice Hsu
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Chonnam National University, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Amir Shaban
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | | | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Richard Williamson
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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12
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Ironside N, Chen CJ, Chalhoub RM, Wludyka P, Kellogg RT, Al Kasab S, Ding D, Maier I, Rai A, Jabbour P, Kim JT, Wolfe SQ, Starke RM, Psychogios MN, Shaban A, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Polifka AJ, Mascitelli JR, Osbun JW, Matouk C, Levitt MR, Dumont TM, Cuellar-Saenz HH, Williamson R, Romano DG, Crosa RJ, Gory B, Mokin M, Moss M, Limaye K, Kan P, Spiotta AM, Park MS. Risk factors and predictors of intracranial hemorrhage after mechanical thrombectomy in acute ischemic stroke: insights from the Stroke Thrombectomy and Aneurysm Registry (STAR). J Neurointerv Surg 2023; 15:e312-e322. [PMID: 36725360 PMCID: PMC10962911 DOI: 10.1136/jnis-2022-019513] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/02/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Reducing intracranial hemorrhage (ICH) can improve patient outcome in acute ischemic stroke (AIS) intervention. We sought to identify ICH risk factors after AIS thrombectomy. METHODS This is a retrospective review of the Stroke Thrombectomy and Aneurysm Registry (STAR) database. All patients who underwent AIS thrombectomy with available ICH data were included. Multivariable regression models were developed to identify predictors of ICH after thrombectomy. Subgroup analyses were performed stratified by symptom status and European Cooperative Acute Stroke Study (ECASS) grade. RESULTS The study cohort comprised 6860 patients. Any ICH and symptomatic ICH (sICH) occurred in 25% and 7% of patients, respectively. Hemorrhagic infarction 1 (HI1) occurred in 36%, HI2 in 24%, parenchymal hemorrhage 1 (PH1) in 22%, and PH2 in 17% of patients classified by ECASS grade. Intraprocedural complications independently predicted any ICH (OR 3.8083, P<0.0001), PH1 (OR 1.9053, P=0.0195), and PH2 (OR 2.7347, P=0.0004). Race also independently predicted any ICH (black: OR 0.5180, P=0.0017; Hispanic: OR 0.4615, P=0.0148), sICH (non-white: OR 0.4349, P=0.0107), PH1 (non-white: OR 3.1668, P<0.0001), and PH2 (non-white: OR 1.8689, P=0.0176), with white as the reference. Primary mechanical thrombectomy technique also independently predicted ICH. ADAPT (A Direct Aspiration First Pass Technique) was a negative predictor of sICH (OR 0.2501, P<0.0001), with stent retriever as the reference. CONCLUSIONS This study identified ICH risk factors after AIS thrombectomy using real-world data. There was a propensity towards a reduced sICH risk with direct aspiration. Procedural complications and ethnicity were predictors congruent between categories of any ICH, sICH, PH1, and PH2. Further investigation of technique and ethnicity effects on ICH and outcomes after AIS thrombectomy is warranted.
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Affiliation(s)
- Natasha Ironside
- Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Reda M Chalhoub
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Peter Wludyka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Ryan T Kellogg
- Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Dale Ding
- Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Gwangju, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Amir Shaban
- Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Joshua W Osbun
- Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | | | | | - Daniele G Romano
- Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | | | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Maxim Mokin
- Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Mark Moss
- Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | | | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Min S Park
- Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
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13
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Harnisch LO, Neugebauer S, Mihaylov D, Eidizadeh A, Zechmeister B, Maier I, Moerer O. Quantification of Bile Acids in Cerebrospinal Fluid: Results of an Observational Trial. Biomedicines 2023; 11:2947. [PMID: 38001948 PMCID: PMC10669160 DOI: 10.3390/biomedicines11112947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
(1) Background: Bile acids, known as aids in intestinal fat digestion and as messenger molecules in serum, can be detected in cerebrospinal fluid (CSF), although the blood-brain barrier is generally an insurmountable obstacle for bile acids. The exact mechanisms of the occurrence, as well as possible functions of bile acids in the central nervous system, are not precisely understood. (2) Methods: We conducted a single-center observational trial. The concentrations of 15 individual bile acids were determined using an in-house LC-MS/MS method in 54 patients with various acute and severe disorders of the central nervous system. We analyzed CSF from ventricular drainage taken within 24 h after placement, and blood samples were drawn at the same time for the presence and quantifiability of 15 individual bile acids. (3) Results: At a median time of 19.75 h after a cerebral insult, the concentration of bile acids in the CSF was minute and almost negligible. The CSF concentrations of total bile acids (TBAs) were significantly lower compared to the serum concentrations (serum 0.37 µmol/L [0.24, 0.89] vs. 0.14 µmol/L [0.05, 0.43]; p = 0.033). The ratio of serum-to-CSF bile acid levels calculated from the respective total concentrations were 3.10 [0.94, 14.64] for total bile acids, 3.05 for taurocholic acid, 14.30 [1.11, 27.13] for glycocholic acid, 0.0 for chenodeoxycholic acid, 2.19 for taurochenodeoxycholic acid, 1.91 [0.68, 8.64] for glycochenodeoxycholic acid and 0.77 [0.0, 13.79] for deoxycholic acid; other bile acids were not detected in the CSF. The ratio of CSF-to-serum S100 concentration was 0.01 [0.0, 0.02]. Serum total and conjugated (but not unconjugated) bilirubin levels and serum TBA levels were significantly correlated (total bilirubin p = 0.031 [0.023, 0.579]; conjugated bilirubin p = 0.001 [0.193, 0.683]; unconjugated p = 0.387 [-0.181, 0.426]). No correlations were found between bile acid concentrations and age, delirium, intraventricular blood volume, or outcome measured on a modified Rankin scale. (4) Conclusions: The determination of individual bile acids is feasible using the current LC-MS/MS method. The results suggest an intact blood-brain barrier in the patients studied. However, bile acids were detected in the CSF, which could have been achieved by active transport across the blood-brain barrier.
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Affiliation(s)
- Lars-Olav Harnisch
- Department of Anaesthesiology, University Medical Center, University of Göttingen, Robert-Koch-Str. 40, D-37075 Göttingen, Germany;
| | - Sophie Neugebauer
- Institute of Clinical Chemistry and Laboratory Diagnostics, University Hospital Jena, Am Klinikum 1, D-07747 Jena, Germany; (S.N.); (D.M.)
| | - Diana Mihaylov
- Institute of Clinical Chemistry and Laboratory Diagnostics, University Hospital Jena, Am Klinikum 1, D-07747 Jena, Germany; (S.N.); (D.M.)
| | - Abass Eidizadeh
- Interdisciplinary UMG Laboratories, University Medical Center, University of Göttingen, Robert-Koch-Str. 40, D-37075 Göttingen, Germany; (A.E.); (B.Z.)
| | - Bozena Zechmeister
- Interdisciplinary UMG Laboratories, University Medical Center, University of Göttingen, Robert-Koch-Str. 40, D-37075 Göttingen, Germany; (A.E.); (B.Z.)
| | - Ilko Maier
- Department of Neurology, University Medical Center, University of Göttingen, Robert-Koch-Str. 40, D-37075 Göttingen, Germany;
| | - Onnen Moerer
- Department of Anaesthesiology, University Medical Center, University of Göttingen, Robert-Koch-Str. 40, D-37075 Göttingen, Germany;
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14
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Ash M, Dimisko L, Chalhoub RM, Howard BM, Cawley CM, Matouk C, Pabaney A, Spiotta AM, Jabbour P, Maier I, Wolfe SQ, Rai AT, Kim JT, Psychogios MN, Mascitelli JR, Starke RM, Shaban A, Yoshimura S, De Leacy R, Kan P, Fragata I, Polifka AJ, Arthur AS, Park MS, Crosa RJ, Williamson R, Dumont TM, Levitt MR, Al Kasab S, Tjoumakaris SI, Liman J, Saad H, Samaniego EA, Fargen KM, Grossberg JA, Alawieh A. Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients. J Neurointerv Surg 2023:jnis-2023-020792. [PMID: 37875342 DOI: 10.1136/jnis-2023-020792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT. METHODS This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation. RESULTS Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time. CONCLUSIONS In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.
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Affiliation(s)
- Makenna Ash
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laurie Dimisko
- Nell Hodgson Woodruff School of Nursing, Emory Healthcare, Atlanta, Georgia, USA
| | - Reda M Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar T Rai
- Department of Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Joon-Tae Kim
- Department of Neurosurgery and Radiology, Chonnam National University, Gwangju, Jeollanam-do, Korea
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- University of Miami School of Medicine, Miami, Florida, USA
| | - Amir Shaban
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Min S Park
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Richard Williamson
- Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jan Liman
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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15
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Won SY, Melkonian R, Behmanesh B, Bernstock JD, Czabanka M, Dubinski D, Freiman TM, Günther A, Hellmuth K, Hernandez-Duran S, Herrmann E, Konczalla J, Maier I, Mielke D, Naser P, Rohde V, Schaefer JH, Senft C, Storch A, Trnovec S, Unterberg A, Walter J, Walter U, Wittstock M, Dinc N, Gessler F. Cerebellar Stroke Score and Grading Scale for the Prediction of Mortality and Outcomes in Ischemic Cerebellar Stroke. Stroke 2023; 54:2569-2575. [PMID: 37551591 DOI: 10.1161/strokeaha.123.043478] [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: 04/05/2023] [Accepted: 07/18/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Several individual predictors for outcomes in patients with cerebellar stroke (CS) have been previously identified. There is, however, no established clinical score for CS. Therefore, the aim of this study was to develop simple and accurate grading scales for patients with CS in an effort to better estimate mortality and outcomes. METHODS This multicentric retrospective study included 531 patients with ischemic CS presenting to 5 different academic neurosurgical and neurological departments throughout Germany between 2008 and 2021. Logistic regression analysis was performed to determine independent predictors related to 30-day mortality and unfavorable outcome (modified Rankin Scale score of 4-6). By weighing each parameter via calculation of regression coefficients, an ischemic CS-score and CS-grading scale (CS-GS) were developed and internally validated. RESULTS Independent predictors for 30-day mortality were aged ≥70 years (odds ratio, 5.2), Glasgow Coma Scale score 3 to 4 at admission (odds ratio, 2.6), stroke volume ≥25 cm3 (odds ratio, 2.7), and involvement of the brain stem (odds ratio, 3.9). When integrating each parameter into the CS-score, age≥70 years and brain stem stroke were assigned 2 points, Glasgow Coma Scale score 3 to 4, and stroke volume≥25 cm3 1 point resulting in a score ranging from 0 to 6. CS-score of 0, 1, 2, 3, 4, 5, and 6 points resulted in 30-day mortality of 1%, 6%, 6%, 17%, 21%, 55%, and 67%, respectively. Independent predictors for 30-day unfavorable outcomes consisted of all components of the CS-score with an additional variable focused on comorbidities (CS-GS). Except for Glasgow Coma Scale score 3 to 4 at admission, which was assigned 3 points, all other parameters were assigned 1 point resulting in an overall score ranging from 0 to 7. CS-GS of 0, 1, 2, 3, 4, 5, 6, and 7 points resulted in 30-day unfavorable outcome of 1%, 17%, 33%, 40%, 50%, 80%, 77%, and 100%, respectively. Both 30-day mortality and unfavorable outcomes increased with increasing CS-score and CS-GS (P<0.001). CONCLUSIONS The CS-score and CS-GS are simple and accurate grading scales for the prediction of 30-day mortality and unfavorable outcome in patients with CS. While the score systems proposed here may not directly impact treatment decisions, it may help discuss mortality and outcome with patients and caregivers.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Ruzanna Melkonian
- Department of Neurosurgery (R.M., C.S., N.D.), Jena University Hospital, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (J.D.B.)
| | - Marcus Czabanka
- Department of Neurosurgery, University Hospital, Goethe University Hospital, Frankfurt, Germany (M.C., J.K.)
| | - Daniel Dubinski
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Thomas M Freiman
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Albrecht Günther
- Department of Neurology (A.G.), Jena University Hospital, Germany
| | - Kara Hellmuth
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Silvia Hernandez-Duran
- Department of Neurosurgery, Göttingen University Hospital, Germany (S.H.-D., D.M., V.R.)
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University Hospital, Frankfurt am Main, Germany (E.H.)
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University Hospital, Frankfurt, Germany (M.C., J.K.)
| | - Ilko Maier
- Department of Neurology, Göttingen University Hospital, Germany (I.M.)
| | - Dorothee Mielke
- Department of Neurosurgery, Göttingen University Hospital, Germany (S.H.-D., D.M., V.R.)
| | - Paul Naser
- Department of Neurosurgery, University of Heidelberg, Germany (P.N., A.U., J.W.)
| | - Veit Rohde
- Department of Neurosurgery, Göttingen University Hospital, Germany (S.H.-D., D.M., V.R.)
| | | | - Christian Senft
- Department of Neurosurgery (R.M., C.S., N.D.), Jena University Hospital, Germany
| | - Alexander Storch
- Department of Neurology (A.S., U.W., M.W.), University Medical Center Rostock, Germany
| | - Svorad Trnovec
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Germany (P.N., A.U., J.W.)
| | - Johannes Walter
- Department of Neurosurgery, University of Heidelberg, Germany (P.N., A.U., J.W.)
| | - Uwe Walter
- Department of Neurology (A.S., U.W., M.W.), University Medical Center Rostock, Germany
| | - Matthias Wittstock
- Department of Neurology (A.S., U.W., M.W.), University Medical Center Rostock, Germany
| | - Nazife Dinc
- Department of Neurosurgery (R.M., C.S., N.D.), Jena University Hospital, Germany
| | - Florian Gessler
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
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16
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Alawieh AM, Chalhoub RM, Al Kasab S, Jabbour P, Psychogios MN, Starke RM, Arthur AS, Fargen KM, De Leacy R, Kan P, Dumont TM, Rai A, Crosa RJ, Maier I, Goyal N, Wolfe SQ, Cawley CM, Mocco J, Tjoumakaris SI, Howard BM, Dimisko L, Saad H, Ogilvy CS, Crowley RW, Mascitelli JR, Fragata I, Levitt MR, Kim JT, Park MS, Gory B, Polifka AJ, Matouk C, Grossberg JA, Spiotta AM. Multicenter investigation of technical and clinical outcomes after thrombectomy for distal vessel occlusion by frontline technique. J Neurointerv Surg 2023; 15:e93-e101. [PMID: 35918129 DOI: 10.1136/jnis-2022-019023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/12/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited. METHODS This was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retriever RESULTS: We included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, p<0.05) irrespective of technique. Younger age, bridging therapy, and lower admission National Institutes of Health Stroke Scale (NIHSS) were also predictors of good outcome. Procedure time ≤1 hour or ≤3 thrombectomy attempts were independent predictors of good outcomes in DVOs irrespective of technique (aOR 4.5 and 2.3, respectively, p<0.05). There were no differences in outcomes in a DVO matched cohort of aspiration versus stent retriever. Rates of hemorrhage and good outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group and attempts in the stent retriever group. CONCLUSIONS Outcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.
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Affiliation(s)
- Ali M Alawieh
- Department of Neurosurgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
| | - Reda M Chalhoub
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | | | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Nitin Goyal
- Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
| | - J Mocco
- Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
| | | | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
- Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
| | | | | | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joon-Tae Kim
- Neurology, Chonnam National University, Gwangju, Jeollanam-do, Korea (the Republic of)
| | - Min S Park
- Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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17
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Schulze-Zachau V, Brehm A, Ntoulias N, Krug N, Tsogkas I, Blackham KA, Möhlenbruch MA, Jesser J, Cervo A, Kreiser K, Althaus K, Maslias E, Michel P, Saliou G, Riegler C, Nolte CH, Maier I, Jamous A, Rautio R, Ylikotila P, Fargen KM, Wolfe SQ, Castellano D, Boghi A, Kaiser DPO, Cuberi A, Kirschke JS, Schwarting J, Limbucci N, Renieri L, Al Kasab S, Spiotta AM, Fragata I, Rodriquez-Ares T, Maurer CJ, Berlis A, Moreu M, López-Frías A, Pérez-García C, Commodaro C, Pileggi M, Mascitelli J, Giordano F, Casagrande W, Purves CP, Bester M, Flottmann F, Kan PT, Edhayan G, Hofmeister J, Machi P, Kaschner M, Weiss D, Katan M, Fischer U, Psychogios MN. Incidence and outcome of perforations during medium vessel occlusion compared with large vessel occlusion thrombectomy. J Neurointerv Surg 2023:jnis-2023-020531. [PMID: 37524518 DOI: 10.1136/jnis-2023-020531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Vessel perforation during thrombectomy is a severe complication and is hypothesized to be more frequent during medium vessel occlusion (MeVO) thrombectomy. The aim of this study was to compare the incidence and outcome of patients with perforation during MeVO and large vessel occlusion (LVO) thrombectomy and to report on the procedural steps that led to perforation. METHODS In this multicenter retrospective cohort study, data of consecutive patients with vessel perforation during thrombectomy between January 1, 2015 and September 30, 2022 were collected. The primary outcomes were independent functional outcome (ie, modified Rankin Scale 0-2) and all-cause mortality at 90 days. Binomial test, chi-squared test and t-test for unpaired samples were used for statistical analysis. RESULTS During 25 769 thrombectomies (5124 MeVO, 20 645 LVO) in 25 stroke centers, perforation occurred in 335 patients (1.3%; mean age 72 years, 62% female). Perforation occurred more often in MeVO thrombectomy (2.4%) than in LVO thrombectomy (1.0%, p<0.001). More MeVO than LVO patients with perforation achieved functional independence at 3 months (25.7% vs 10.9%, p=0.001). All-cause mortality did not differ between groups (overall 51.6%). Navigation beyond the occlusion and retraction of stent retriever/aspiration catheter were the two most common procedural steps that led to perforation. CONCLUSIONS In our cohort, perforation was approximately twice as frequent in MeVO than in LVO thrombectomy. Efforts to optimize the procedure may focus on navigation beyond the occlusion site and retraction of stent retriever/aspiration catheter. Further research is necessary in order to identify thrombectomy candidates at high risk of intraprocedural perforation and to provide data on the effectiveness of endovascular countermeasures.
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Affiliation(s)
- Victor Schulze-Zachau
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Nikolaos Ntoulias
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Nadja Krug
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Ioannis Tsogkas
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Kristine Ann Blackham
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Markus A Möhlenbruch
- Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Amedeo Cervo
- Neuroradiology Department, Niguarda Hospital, Milan, Italy
| | - Kornelia Kreiser
- Radiology and Neuroradiology Clinic, RKU - Universitäts- und Rehabilitationskliniken Ulm gGmbH, Ulm, Germany
| | | | - Errikos Maslias
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- UNIL - Université de Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- UNIL - Université de Lausanne, Lausanne, Switzerland
| | - Guillaume Saliou
- UNIL - Université de Lausanne, Lausanne, Switzerland
- Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ala Jamous
- Department of Diagnostic & Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Riitta Rautio
- Department of Radiology, Turku University Hospital, Turku, Finland
| | | | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Davide Castellano
- Department of Interventional Radiology and Neuroradiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Andrea Boghi
- Department of Interventional Radiology and Neuroradiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Daniel P O Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ani Cuberi
- Department of Radiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan S Kirschke
- Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Julian Schwarting
- Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Nicola Limbucci
- Department of Neurovascular Intervention, Azienda Ospedaliero Universitaria Careggio, Florence, Italy
| | - Leonardo Renieri
- Department of Neurovascular Intervention, Azienda Ospedaliero Universitaria Careggio, Florence, Italy
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central EPE, Lisbon, Portugal
- NOVA Medical School, Lisbon, Portugal
| | - Tania Rodriquez-Ares
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central EPE, Lisbon, Portugal
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Manuel Moreu
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Alfonso López-Frías
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Carlos Pérez-García
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Christian Commodaro
- Diagnostic and Interventional Neuroradiology Department, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Marco Pileggi
- Diagnostic and Interventional Neuroradiology Department, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Justin Mascitelli
- Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli, Naples, Italy
| | - Walter Casagrande
- Neurosurgery Department, Hospital General de Agudos Juan A Fernandez, Buenos Aires, Argentina
| | - Cynthia P Purves
- Neurosurgery Department, Hospital General de Agudos Juan A Fernandez, Buenos Aires, Argentina
| | - Maxim Bester
- Diagnostic and Interventional Neuroradiology Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Diagnostic and Interventional Neuroradiology Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter T Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Gautam Edhayan
- Department of Radiology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jeremy Hofmeister
- Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Paolo Machi
- Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Weiss
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Mira Katan
- Neurology Clinic, University Hospital Basel, Basel, Switzerland
| | - Urs Fischer
- Neurology Clinic, University Hospital Basel, Basel, Switzerland
| | - Marios-Nikos Psychogios
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
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18
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Saad HW, Eshraghi S, Howard BM, Buster BE, Akbik F, Maier I, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios M, Jabbour P, DeLeacy R, Dumont TM, Kan P, Arthur AS, Crosa R, Gory B, Spiotta AM, Alawieh AM, Grossberg JA. 476 Technical and Clinical Outcomes in Concurrent Multivessel Occlusions Treated With Mechanical Thrombectomy: Insights from the STAR Collaboration. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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19
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Essibayi MA, Anadani M, Almallouhi E, Yaghi S, Maier I, Jabbour PM, Kim JT, Wolfe SQ, Rai A, Starke R, Psychogios M, Shaban A, Arthur AS, Yoshimura S, Howard B, Alawieh A, Fragata I, Cuellar H, Polifka A, Mascitelli J, Osbun J, Matouk C, Park MS, Levitt M, Dumont T, Williamson R, Altschul D, Spiotta AM, Al Kasab S. Abstract WP164: Acute Carotid Stenting Versus Conservative Management For Tandem Carotid Occlusions: Insights From STAR. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Management of anterior circulation emergent large vessel occlusion with tandem carotid occlusion (TCO) remains a challenge during mechanical thrombectomy (MT). To day, there is no consensus regarding emergent carotid stenting (ECS) in the setting of MT with TCO. We aimed to compare the outcomes of ECS versus conservative management (MT alone) among patients with TCO.
Methods:
Data from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 was interrogated. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the ICA or MCA were included in the analyses. We compared baseline, procedural charecteristics, successful reperfusion (mTICI 2b-3), favorable 90-day good outcomes (mRS 0-2), intravenous tPA administration and symptomatic ICH between patients who did or did not undergo ECS. Multivariate regression was performed adjusting for variables of clinical importance. Propensity score matching for IV tPA use was performed to explore its safety with stenting.
Results:
Among 9812 thrombectomy patients, 688 patients had TCO; 132 underwent emergent stenting and 444 had MT alone. Patients who did not undergo ECS had a higher prevalence of atrial fibrillation (33.9% Vs 9.2%, P<.001), higher admission NIHSS scores (18 Vs 14, P<.001), shorter time from symptom onset to puncture (275 minutes Vs 333 minutes, P=0.029), and were predominantly women (59.2% Vs 33.6%, P<0.001).Patients with stenting had lower mortality rates ( 17.5% Vs 29.6%, P=0.009), and higher rates of successful reperfusion (83% Vs 95%, P=0.001). No difference in mRS 0-2 (37.5% Vs 30.4%, P=0.178) or sICH were seen (11.1% Vs 15.4%, P=0.219). Propensity score matching analysis (n=129 in each group) demonstrated better rates of reperfusion (94.8 Vs 84.4%, P=0.011) in the stenting group. Advanced age, higher admission NIHSS and lower ASPECT scores were associated with worse clinical outcomes.
Conclusion:
ECS during MT for TCO appears to be safe and is associated with better clinical and angiographic outcomes compared to conservative management.
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Affiliation(s)
| | | | | | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
| | | | | | | | | | | | | | | | | | | | - Isabel Fragata
- Cntr Hospar Universitário de Lisboa Central, Lisbon, Portugal
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20
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Almallouhi E, Al Kasab S, Maier I, Jabbour PM, Kim JT, Quintero Wolfe SC, rai A, Starke R, Psychogios M, Samaniego EA, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Cuellar H, Polifka A, Mascitelli J, Osbun J, Matouk C, Park MS, Levitt M, Dumont T, Williamson R, Spiotta AM, Grandhi R. Abstract 48: Outcomes And Risk Of Hemorrhagic Transformation Following Mechanical Thrombectomy In Primary Distal Posterior Cerebral Artery Occlusions-subgroup Analysis From STAR. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
While mechanical thrombectomy (MT) has become the standard of care for acute stroke patients presenting with large vessel occlusion (LVO) and salvageable brain tissue, limited data is currently available regarding the benefits of MT in patents with medium vessel occlusions (MeVO) especially in the posterior circulation (P2 occlusions).
Methods:
We used the Stroke Thrombectomy and Aneurysm registry (STAR) which included data from 35 stroke centers in North America, Europe, Asia, and South America. We included patients who presented with MeVO in the M2, M3 or P2 segments and underwent MT. We used a Generalized Linear Model to assess the relationship between location of occlusion and outcomes.
Results:
9812 patients were included in STAR at the time of this analysis; 43 underwent MT for P2 occlusion, 130 underwent MT for M3 occlusion; and 1273 underwent MT for M2 occlusion. There was no difference in age, sex, race, rate of IV-tPA and stroke severity between patients in all 3 groups (Table 1). There was a trend toward lower rate of atrial fibrillation in patients with P2 and M3 occlusions. Patients with P2 occlusions were less likely to achieve successful recanalization (modified treatment in cerebral infarction score≥2b); intraarterial thrombolysis was used less in P2 occlusions (4.7% compared to 16.2% in M3 occlusions and 10.1% in M2 occlusions). However, there was no difference in the rate of successful first pass. On multivariable analysis, P2 occlusions were not associated with hemorrhagic transformation (OR 2.0, 95% CI 0.7-5.7, P 0.186), 90-day mortality (OR 0.5, 95% CI 0.2-1.4, P 0.183), or 90-day favorable outcome (OR 2.0, 95% CI 0.9-4.4, P 0.084).
Conclusions:
In this multicenter study, there was no significant difference in safety and efficacy of MT in patients with MeVOs in posterior circulation (P2 occlusions) compared to M2 and M3 occlusions. Improved techniques for successful recanalization are needed for posterior circulation MeVOs.
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Affiliation(s)
| | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
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21
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Almallouhi E, Anadani M, Al Kasab S, Maier I, Jabbour PM, Kim JT, Quintero Wolfe SC, rai A, Starke R, Psychogios M, Samaniego EA, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Cuellar H, Polifka A, Mascitelli J, Osbun J, Matouk C, Park MS, Levitt M, Dumont T, Williamson R, Spiotta AM. Abstract 98: The Impact Of Aspiration Catheter Size On Thrombectomy Outcomes Using Adapt Technique-analysis From The STAR Registry. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introductions:
Clinical trials have shown that aspiration thrombectomy is as safe and effective as stent-retriever thrombectomy. Multiple improvements have been made to the aspiration technique over the last few years. In this study, we aim to assess the effect of aspiration catheter bore size on the outcomes of A direct aspiration first pass technique (ADAPT) thrombectomy.
Methods:
We included patients who underwent ADAPT thrombectomy for M1 or internal carotid artery terminus (ICA-T) occlusions in the Stroke Thrombectomy and Aneurysm (STAR) database. Patients included between July 2016 and July 2022. We compared baseline characteristics, procedural metrics and outcomes between patients who underwent thrombectomy using small bore (0.035”-0.060”), medium bore (0.062”-0.068”) and large bore (0.070”-0.074”) catheters.
Results:
A total of 1158 patients were included; 576 (49.7%) females, 645 (70%) White, and 464 (40.6%) received IV-tPA. No difference was noticed in age, sex, and vascular risk factors between the 3 different groups. There was higher rate of IV-tPA in the small-bore catheter group (48.8%) compared to the medium and large bore catheter groups (38.4% and 36.7%, respectively) (P=0.03). Procedure duration was shorter when using medium (20 min) and large (18 min) compared to small bore catheters (30 min) (P=0.01). Both medium and large bore catheters were associated with higher rate of successful recanalization (88.9% and 87.9%, respectively) compared to small bore catheters (81.6%) (P=0.010). However, the difference in successful recanalization or procedure duration between medium and large bore catheters was not significant. No difference was noted in the rate of symptomatic hemorrhagic transformation (sICH) (4.7%, 5.3%, and 7.1%; P=0.345), 90-day favorable outcome (modified Rankin Scale 0-2) (41.8%, 39.3%, 40.8%; P=0.766) or 90-day mortality (18.1%, 23.5%, 24.4%; P=0.111) between the groups.
Conclusions:
Higher rate of successful recanalization and shorter procedure duration were observed when using medium and large bore aspiration catheters compared with small bore catheters in ADAPT technique. However, these procedural benefits were not observed when comparing large bore to medium bore catheters.
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Affiliation(s)
| | | | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
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22
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Essibayi MA, Anadani M, Almallouhi E, Yaghi S, Lajthia O, Maier I, Jabbour PM, Kim JT, Quintero Wolfe S, rai A, Starke R, Psychogios M, Shaban A, Arthur AS, Yoshimura S, Howard B, Alawieh A, Fragata I, Cuellar H, Polifka A, Mascitelli J, Osbun J, Matouk C, Park MS, Levitt M, Dumont T, Williamson R, Altschul D, Spiotta AM, Al Kasab S. Abstract TP154: Outcomes Of Acute Carotid Stenting With Or Without Intravenous Thrombolysis Among Patients With Acute Tandem Occlusion: Insights From STAR. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Emergency carotid artery stenting during mechanical thrombectomy has emerged as an effective emergent treatment for tandem carotid occlusions. Nevertheless, scarce evidence is available about the safety of this procedure in patients who received intravenous tPA before thrombectomy. Herein, we investigate the safety of acute carotid stenting among patients who received intravenous tPA in a large international multicenter registry.
Methods:
Patients from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 were analyzed. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the internal carotid or middle cerebral artery were included in the final analyses. Patients were divided into two groups, depending on tPA administration. The primary outcome was 90-day good clinical outcome (mRS 0-2), and the primary safety outcome was symptomatic intracranial hemorrhage. Univariate and multivariate regressions were performed adjusting for variables of clinical importance.
Results:
Among 9812 with acute ischemic stroke in the registry, 132 patients had acute tandem occlusion and underwent carotid stenting; of those, 60 patients received IV tPA. Compared to non-intravenous thrombolytics, patients with IV tPA had a higher male prevalence (78.3% Vs 54.4%, P=0.005) and better ASPECT scores (9 Vs 8, P=0.022) with a shorter time from onset to puncture (241 Vs 672 minutes, P<0.001). There was no difference in rates of successful revascularization (94% Vs 95.5%, P=NS), good clinical outcome (50.8% Vs 61.4%, P=NS), symptomatic intracranial hemorrhage (15.3% Vs 14.5%, P=NS) or procedural complications (15% Vs 11.6%, P=NS) between the tPA and non-tPA groups.
Conclusion:
The use of IV tPA did not affect the safety or efficacy of emergent carotid stenting in the setting of acute tandem occlusion.
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Affiliation(s)
| | | | | | | | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
| | | | | | | | | | | | | | | | | | | | - Isabel Fragata
- Cntr Hospar Universitário de Lisboa Central, Lisbon, Portugal
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23
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Hafeez MU, Essibayi MA, Raper D, Tanweer O, Sattur M, Al-Kasab S, Burks J, Townsend R, Alsbrook D, Dumont T, Park MS, Goyal N, Arthur AS, Maier I, Mascitelli J, Starke R, Wolfe S, Fargen K, Spiotta A, Kan PT. Predictors and outcomes of first pass efficacy in posterior circulation strokes: Insights from STAR collaboration. Interv Neuroradiol 2022:15910199221149080. [PMID: 36579794 DOI: 10.1177/15910199221149080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: First-pass efficacy (FPE) has been established as an important predictor of favorable functional outcomes after endovascular thrombectomy (ET) in anterior circulation strokes. In this retrospective cohort study, we investigate predictors and clinical outcomes of FPE in posterior circulation strokes (pcAIS). Methods: The Stroke Thrombectomy and Aneurysm Registry database was used to identify pcAIS patients who achieved FPE. Their baseline characteristics and outcomes were compared with the non-FPE group. The primary outcome was a 90-day modified Rankin Scale (mRS) of 0-3. Univariate (UVA) and multivariate (MVA) analyses were done to evaluate predictors of FPE. Safety outcomes included distal emboli, vessel rupture, symptomatic intracranial hemorrhage, and mortality. Results: Of 359 patients, 179 (50%) achieved FPE. Clot burden, occlusion site, and ET technique-related variables were similar between the two groups except for shorter procedure time with FPE. The primary outcome was significantly better with FPE (56.4% vs. 32.8%, p < 0.001). Complications were similar except for a higher rate of distal emboli in non-FPE group (11.1% vs. 3.2%, p = 0.032). Atrial fibrillation (Afib) had increased odds (aOR: 2.06, 95% CI; 1.24, 3.4, p = 0.005) and prior ischemic stroke had decreased odds (aOR: 0.524, 95% CI; 0.28, 0.97, p = 0.04) of FPE. Afib was the only independent predictor of FPE on MVA (1.94, 95% CI; 1.1, 3.43, p = 0.022). Conclusions: Higher rate of FPE in Afib-related pcAIS could possibly be explained by the differences in clot composition and degree of in-situ atherosclerotic disease burden. Future studies are warranted to explore the relationship of clot composition with ET outcomes.
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Affiliation(s)
- Muhammad U Hafeez
- Department of Neurology, 3989Baylor College of Medicine, Houston, TX, USA
| | - Muhammed A Essibayi
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Daniel Raper
- Department of Neurosurgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - Omar Tanweer
- Department of Neurosurgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - Mithun Sattur
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Sami Al-Kasab
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Joshua Burks
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
| | - Robert Townsend
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Diana Alsbrook
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tuscon, AZ, USA
| | - Min S Park
- Department of Neurosurgery, 2358University of Virginia, Charlottesville, VA, USA
| | - Nitin Goyal
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Justin Mascitelli
- Department of Neurosurgery, 14742University of Texas Health Science Center, San Antonio, TX, USA
| | - Robert Starke
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
| | - Stacey Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kyle Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alejandro Spiotta
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Peter T Kan
- Department of Neurosurgery, 12338University of Texas Medical Branch, Galveston, TX, USA
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24
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Grossberg JA, Chalhoub RM, Al Kasab S, Pullmann D, Jabbour P, Psychogios M, Starke RM, Arthur AS, Fargen KM, De Leacy R, Kan P, Dumont T, Rai A, Crosa RJ, Naamani KE, Maier I, Goyal N, Wolfe SQ, Michael Cawley C, Mocco J, Hafeez M, Howard BM, Dimisko L, Saad H, Ogilvy CS, Webster Crowley R, Mascitelli J, Fragata I, Levitt M, Spiotta AM, Alawieh AM. Multicenter investigation of technical and clinical outcomes after thrombectomy for Proximal Medium Vessel Occlusion (pMeVO) by frontline technique. Interv Neuroradiol 2022:15910199221138139. [PMID: 36377352 DOI: 10.1177/15910199221138139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited. METHODS We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015-2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever. RESULTS In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p = 0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p < 0.05), procedure time ≤ 1-h(aOR = 2.2,p < 0.05), and thrombectomy attempts ≤ 4(aOR = 2.8,p < 0.05) were independent predictors of good-outcomes.In a propensity-matched cohort of aspiration versus stent-retriever pMeVO patients, there was no difference in good-outcomes. The rates of hemorrhage were higher(9%vs.4%,p < 0.01) and procedure time longer(51-min vs. 33-min,p < 0.01) with stent-retriever, while the number of attempts was higher with aspiration(2.5vs.2,p < 0.01). Rates of hemorrhage and good-outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group compared to attempts in the stent-retriever group. CONCLUSIONS Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.
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Affiliation(s)
- Jonathan A Grossberg
- Department of Neurosurgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Reda M Chalhoub
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Sami Al Kasab
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Dominika Pullmann
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Robert M Starke
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor University, Houston, TX, USA
| | - Travis Dumont
- Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Ansaar Rai
- Department of Radiology, West Virginia School of Medicine, Morgantown, WV, USA
| | - Roberto J Crosa
- Department of Neurosurgery, Centro Endovascular Neurologico Medica Uruguaya, Montevideo, Uruguay
| | - Kareem E Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - C Michael Cawley
- Department of Neurosurgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | - Muhammad Hafeez
- Department of Neurosurgery, Baylor University, Houston, TX, USA
| | - Brian M Howard
- Department of Neurosurgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Laurie Dimisko
- Department of Neurosurgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Hassan Saad
- Department of Neurosurgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Christopher S Ogilvy
- Department of Neurosurgery, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Justin Mascitelli
- Department of Neurosurgery, University of Texas San Antonio, San Antonio, TX, USA
| | - Isabel Fragata
- Neuroradiology Department, Hospital São José, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Michael Levitt
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Ali M Alawieh
- Department of Neurosurgery, 12239Emory University School of Medicine, Atlanta, GA, USA
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25
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Porto GBF, Chen CJ, Al Kasab S, Essibayi MA, Almallouhi E, Hubbard Z, Chalhoub R, Alawieh A, Maier I, Psychogios MN, Wolfe SQ, Jabbour P, Rai A, Starke RM, Shaban A, Arthur A, Kim JT, Yoshimura S, Grossberg J, Kan P, Fragata I, Polifka A, Osbun J, Mascitelli J, Levitt MR, Williamson R, Romano DG, Crosa R, Gory B, Mokin M, Limaye KS, Casagrande W, Moss M, Grandhi R, Yoo A, Spiotta AM, Park MS. Association of Noncontrast Computed Tomography and Perfusion Modalities With Outcomes in Patients Undergoing Late-Window Stroke Thrombectomy. JAMA Netw Open 2022; 5:e2241291. [PMID: 36367728 PMCID: PMC9652750 DOI: 10.1001/jamanetworkopen.2022.41291] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IMPORTANCE There is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy. OBJECTIVE To assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI). DESIGN, SETTING, AND PARTICIPANTS In this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022. EXPOSURES Selection by NCCT, CTP, or DWI. MAIN OUTCOMES AND MEASURES Primary outcome was functional independence (modified Rankin scale 0-2) at 90 days. RESULTS Among 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups. CONCLUSIONS AND RELEVANCE In this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.
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Affiliation(s)
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | | | - Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Zachary Hubbard
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Reda Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Stacey Q. Wolfe
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ansaar Rai
- Department of Radiology, West Virginia University, Morgantown
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Health System, Miami, Florida
| | - Amir Shaban
- Department of Neurology, University of Iowa, Iowa City
| | - Adam Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston
| | - Isabel Fragata
- Neuroradiology Department, Hospital São José Centro Hospitalar, Lisboa, Portugal
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University in St Louis, St Louis, Missouri
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio
| | | | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Daniele G. Romano
- Department of Radiology, A.O.U.S. Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa
| | | | - Walter Casagrande
- Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina
| | - Mark Moss
- Department of Interventional Neuroradiology, Washington Regional Medical Center, Fayetteville, Arkansas
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City
| | - Albert Yoo
- Department of Neurosurgery, Texas Stroke Institute, Plano
| | | | - Min S. Park
- Department of Neurosurgery, University of Virginia Health, Charlottesville
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26
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Lu VM, Luther EM, Silva MA, Elarjani T, Abdelsalam A, Maier I, Al Kasab S, Jabbour PM, Kim JT, Wolfe SQ, Rai AT, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Polifka A, Mascitelli J, Osbun J, Park MS, Levitt MR, Dumont T, Cuellar H, Williamson RW, Romano DG, Crosa R, Gory B, Mokin M, Moss M, Limaye K, Kan P, Yavagal DR, Spiotta AM, Starke RM. Prognostic significance of age within the adolescent and young adult acute ischemic stroke population after mechanical thrombectomy: insights from STAR. J Neurosurg Pediatr 2022; 30:1-7. [PMID: 35986724 DOI: 10.3171/2022.7.peds22250] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. METHODS A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12-18 (adolescent) and 19-25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. RESULTS Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0-2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to-groin puncture and groin puncture-to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0-6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01). CONCLUSIONS Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.
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Affiliation(s)
- Victor M Lu
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Evan M Luther
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Michael A Silva
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Turki Elarjani
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Ahmed Abdelsalam
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Ilko Maier
- 2Department of Neurology, University Medical Center Gottingen, Gottingen, Germany
| | - Sami Al Kasab
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Pascal M Jabbour
- 4Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joon-Tae Kim
- 5Department of Neurosurgery, Chonnam National University Hospital, Gwangju, South Korea
| | - Stacey Q Wolfe
- 6Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ansaar T Rai
- 7Department of Neuroradiology, University of West Virginia, Morgantown, West Virginia
| | | | | | - Adam S Arthur
- 10Department of Neurosurgery, Semmes Murphey Neurologic and Spine Clinic, Memphis, Tennessee
| | - Shinichi Yoshimura
- 11Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | - Ali Alawieh
- 12Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Isabel Fragata
- 13Department of Neuroradiology, Hospital Sao Jose Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Adam Polifka
- 14Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Justin Mascitelli
- 15Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Joshua Osbun
- 16Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri
| | - Min S Park
- 17Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael R Levitt
- 18Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Travis Dumont
- 19Department of Neurosurgery, University of Arizona, Tucson, Arizona
| | - Hugo Cuellar
- 20Department of Radiology, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Richard W Williamson
- 21Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Daniele G Romano
- 22Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Salerna, Italy
| | - Roberto Crosa
- 23Department of Neurosurgery, Neurological Endovascular Center, Medica Uruguaya, Montevideo, Uruguay
| | - Benjamin Gory
- 24Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- 25Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Mark Moss
- 26Department of Interventional Neuroradiology, Washington Regional Medical, Fayetteville, Arkansas
| | - Kaustubh Limaye
- 27Department of Interventional Neuroradiology, Indiana University, Indianapolis, Indiana; and
| | - Peter Kan
- 28Department of Neurosurgery, University of Texas Medical Branch-Galveston, Galveston, Texas
| | - Dileep R Yavagal
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Alejandro M Spiotta
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Robert M Starke
- 1Department of Neurosurgery, University of Miami, Miami, Florida
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27
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Chen CJ, Chalhoub R, Ding D, Kumar JS, Ironside N, Kellogg RT, Worrall BB, Southerland AM, Jabbour P, Wolfe SQ, Arthur AS, Goyal N, Fragata I, Maier I, Matouk C, Grossberg JA, Kan P, Schirmer CM, Crowley RW, Ares WJ, Ogilvy CS, Rai AT, Levitt MR, Mokin M, Guerrero WR, Mascitelli JR, Yoo AJ, Williamson R, Grande AW, Crosa RJ, Webb S, Psychogios MN, Starke RM, Spiotta AM, Park MS. Is a picture-perfect thrombectomy necessary in acute ischemic stroke? J Neurointerv Surg 2022; 14:111-116. [PMID: 33593800 PMCID: PMC10947782 DOI: 10.1136/neurintsurg-2020-017193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3. METHODS This is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage. RESULTS The unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041). CONCLUSIONS Complete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.
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Affiliation(s)
- Ching-Jen Chen
- Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Reda Chalhoub
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Dale Ding
- Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Jeyan S Kumar
- Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Natasha Ironside
- Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ryan T Kellogg
- Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Bradford B Worrall
- Neurology, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam S Arthur
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | | | | | - William J Ares
- Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Ansaar T Rai
- Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | | | - Justin R Mascitelli
- Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Albert J Yoo
- Neurointerventional Radiology, Texas Stroke Institute, Plano, Texas, USA
| | - Richard Williamson
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Andrew Walker Grande
- Neurosurgery, Radiology and Neurology, University of Minnesota, Mendota Heights, Minnesota, USA
| | | | - Sharon Webb
- Neurosurgery, Bon Secours, Greenville, South Carolina, USA
| | - Marios N Psychogios
- Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Robert M Starke
- Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Min S Park
- Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
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28
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Almallouhi E, Al Kasab S, Hubbard Z, Bass EC, Porto G, Alawieh A, Chalhoub R, Jabbour PM, Starke RM, Wolfe SQ, Arthur AS, Samaniego E, Maier I, Howard BM, Rai A, Park MS, Mascitelli J, Psychogios M, De Leacy R, Dumont T, Levitt MR, Polifka A, Osbun J, Crosa R, Kim JT, Casagrande W, Yoshimura S, Matouk C, Kan PT, Williamson RW, Gory B, Mokin M, Fragata I, Zaidat O, Yoo AJ, Spiotta AM. Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in the Early and Extended Window. JAMA Netw Open 2021; 4:e2137708. [PMID: 34878550 PMCID: PMC8655598 DOI: 10.1001/jamanetworkopen.2021.37708] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 01/22/2023] Open
Abstract
IMPORTANCE Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. OBJECTIVE To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score. EXPOSURE All patients underwent MT in one of the included centers. MAIN OUTCOMES AND MEASURES A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset). RESULTS A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64). CONCLUSIONS AND RELEVANCE In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window.
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Affiliation(s)
- Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Zachary Hubbard
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Eric C. Bass
- Department of Radiology, Medical University of South Carolina, Charleston
| | - Guilherme Porto
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Reda Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Pascal M. Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Health System, Miami, Florida
| | - Stacey Q. Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adam S. Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis
| | - Edgar Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Brian M. Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ansaar Rai
- Department of Radiology, West Virginia School of Medicine, Morgantown
| | - Min S. Park
- Department of Neurosurgery, University of Virginia, Charlottesville
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio
| | | | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tuscon
| | | | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Walter Casagrande
- Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston
| | | | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa
| | - Isabel Fragata
- Neuroradiology Department, Hospital São José Centro Hospitalar, Lisboa, Portugal
| | - Osama Zaidat
- Neuroscience Department, Bon Secours Mercy Health St Vincent Medical Center, Toledo, Ohio
| | - Albert J. Yoo
- Department of Radiology, Texas Stroke Institute, Dallas–Fort Worth
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29
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Akbik F, Alawieh A, Dimisko L, Howard BM, Cawley CM, Tong FC, Nahab F, Samuels OB, Maier I, Feng W, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios MN, Jabbour P, De Leacy R, Keyrouz SG, Dumont TM, Kan P, Liman J, Arthur AS, Wolfe SQ, Mocco J, Crosa RJ, Fox WC, Gory B, Spiotta AM, Grossberg JA. Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes. J Neurointerv Surg 2021; 14:979-984. [PMID: 34819345 DOI: 10.1136/neurintsurg-2021-017954] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/27/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT. METHODS This international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared. RESULTS 6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis. CONCLUSION In this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers.
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Affiliation(s)
- Feras Akbik
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Laurie Dimisko
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Frank C Tong
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Fadi Nahab
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Owen B Samuels
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Wuwei Feng
- Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Nitin Goyal
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Robert M Starke
- Neurosurgery and Radiology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Reade De Leacy
- Neurosurgery, The Mount Sinai Health System, New York, New York, USA
| | - Saleh G Keyrouz
- Department of Neurology, Washington University at St. Louis, St Louis, Missouri, USA
| | - Travis M Dumont
- Surgery, Division of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jan Liman
- Neurology, University Medical Center, Göttingen, Germany
| | - Adam S Arthur
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - J Mocco
- Neurosurgery, The Mount Sinai Health System, New York, New York, USA
| | | | - W Christopher Fox
- Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.,INSERM, IADI, Université de Lorraine, Nancy, France
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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30
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Katsanos AH, Malhotra K, Ahmed N, Seitidis G, Mistry EA, Mavridis D, Kim JT, Veroniki A, Maier I, Matusevicius M, Khatri P, Anadani M, Goyal N, Arthur AS, Sarraj A, Yaghi S, Shoamanesh A, Catanese L, Kantzanou M, Psaltopoulou T, Rentzos A, Psychogios M, Van Adel B, Spiotta AM, Sandset EC, de Havenon A, Alexandrov AV, Petersen NH, Tsivgoulis G. Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis. Neurology 2021; 98:e291-e301. [PMID: 34772799 DOI: 10.1212/wnl.0000000000013049] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). METHODS A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model. RESULTS A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT. CONCLUSION Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada .,Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Georgios Seitidis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Paris Descartes University, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Argie Veroniki
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Ilko Maier
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mohammad Anadani
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Amrou Sarraj
- Department of Neurology, UT Houston, Houston, Texas, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Luciana Catanese
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada
| | - Maria Kantzanou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rentzos
- Diagnostic and Interventional Neuroradiology, Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marios Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Brian Van Adel
- Division of Neurology, Neurosurgery, and Diagnostic Imaging, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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31
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Burks JD, Chen SH, Luther EM, Almallouhi E, Al Kasab S, Jabbour PM, Wolfe SQ, Fargen KM, Arthur AS, Goyal N, Fragata I, Maier I, Matouk C, Grossberg J, Kan P, Schirmer C, Crowley RW, Ares W, Ogilvy CS, Rai AT, Levitt MR, Mokin M, Guerrero W, Park MS, Mascitelli J, Yoo A, Williamson RW, Grande A, Crosa R, Webb S, Psychogios M, Peterson EC, Yavagal DR, Spiotta AM, Starke RM. Effect of Hispanic Status in Mechanical Thrombectomy Outcomes After Ischemic Stroke: Insights From STAR. Stroke 2021; 52:e715-e719. [PMID: 34517765 DOI: 10.1161/strokeaha.120.033326] [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: 11/16/2022]
Abstract
Background and Purpose Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race. Methods Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days. Results Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72–84), compared with 63 years (54–74) for NHB, and 71 years (60–80) for NHW patients (P<0.001). Hispanic patients had a higher incidence of diabetes (41%; P<0.001) and hypertension (82%; P<0.001) compared with NHW and NHB patients. Median procedure time was shorter in Hispanics (36 minutes) compared to NHB (39 minutes) and NHW (44 minutes) patients (P<0.001). In multivariate analysis, Hispanic patients were less likely to have favorable outcome (odds ratio, 0.502 [95% CI, 0.263–0.959]), controlling for other significant predictors (age, admission National Institutes Health Stroke Scale, onset to groin time, number of attempts, procedure time). Conclusions Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.
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Affiliation(s)
- Joshua D Burks
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Stephanie H Chen
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Evan M Luther
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston (E.A., S.A.K., A.M.S.)
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston (E.A., S.A.K., A.M.S.)
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (P.M.J.)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forrest School of Medicine, Winston-Salem, NC (S.Q.W., K.M.F.)
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forrest School of Medicine, Winston-Salem, NC (S.Q.W., K.M.F.)
| | - Adam S Arthur
- Department of Neurosurgery (A.S.A., N.G.), Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN
| | - Nitin Goyal
- Department of Neurosurgery (A.S.A., N.G.), Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN.,Neurology (N.G.), Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN
| | - Isabel Fragata
- Department of Neuroradiology, Hospital Sao Jose Centro Hospitalar Lisboa Central, Lisboa, Portugal (I.F.)
| | - Ilko Maier
- Department of Neurology, University Medical Center Gottingen, Germany (I.M.)
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, CT (C.M.)
| | | | - Peter Kan
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX (P.K.)
| | - Clemens Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, PA (C.S.)
| | | | - William Ares
- Department of Neurosurgery, NorthShore University Health System, Evanston, IL (W.A.)
| | | | - Ansaar T Rai
- Department of Neuroradiology, University of West Virginia, Morgantown (A.T.R.)
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle (M.R.L.)
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa (M.M., W.G.)
| | - Waldo Guerrero
- Department of Neurosurgery, University of South Florida, Tampa (M.M., W.G.)
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville (M.S.P.)
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio (J.M.)
| | - Albert Yoo
- Texas Stroke Institute, Fort Worth (A.Y.)
| | | | - Andrew Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis (A.G.)
| | - Roberto Crosa
- Department of Neurosurgery Centro Endovascular Neurologico Medica Uruguaya Montevideo, Uruguay (R.C.)
| | - Sharon Webb
- Department of Neurosurgery, Bon Secours Health System, Greenville, SC (S.W.)
| | - Marios Psychogios
- Department of Radiology, University Hospital Basel, Switzerland (M.P.)
| | - Eric C Peterson
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Dileep R Yavagal
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston (E.A., S.A.K., A.M.S.)
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
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Gadgil N, Aldave G, Whitehead WE, Dmytriw AA, Chen K, Orbach D, Maier I, Behme D, Fargen KM, Elijovich L, Dornbos D, Spiotta A, Kan P. Endovascular Intervention for Refractory Pediatric Cerebral Venous Sinus Thrombosis. Pediatr Neurol 2021; 121:45-50. [PMID: 34147818 DOI: 10.1016/j.pediatrneurol.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/18/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVST) is a rare but potentially morbid disease in the pediatric population, and the optimal treatment is not fully understood. Endovascular intervention for this condition has been rarely reported. METHODS The Stroke Thrombectomy and Aneurysm Registry was queried for patients aged less than or equal to 18 years undergoing endovascular treatment for CVST in the past 10 years. Clinical charts and radiographic data were retrospectively reviewed. Modified Rankin Score (mRS) at 90 days postprocedure was determined as the primary outcome. RESULTS A total of seven patients across five pediatric centers ranging from 7 to 16 years of age were identified with a mean follow-up of 28 months. All had underlying conditions predisposing to CVST. Endovascular intervention was undertaken due to neurological deterioration despite systemic anticoagulation; venous infarct was evident preoperatively in six of seven patients. Mechanical venous thrombectomy was attempted in all individuals, and intrasinus thrombolytic therapy was also performed in three cases. Six patients had favorable outcome with mRS 0 or 1 at 90 days postprocedure; one remained neurologically devastated. CONCLUSIONS Endovascular treatment by an experienced interventionalist may be safe and effective in severe cases of CVST in children failing frontline therapy. Children with radiographic or clinical progression despite anticoagulation may be considered for endovascular intervention in a timely manner.
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Affiliation(s)
- Nisha Gadgil
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - Guillermo Aldave
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - Adam A Dmytriw
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Karen Chen
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Darren Orbach
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Caroline
| | - Lucas Elijovich
- Department of Neurology and Neurosurgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, Tennessee
| | - David Dornbos
- Department of Neurological Surgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, Tennessee
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas.
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33
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Al Kasab S, Almallouhi E, Alawieh A, Wolfe S, Fargen KM, Arthur AS, Goyal N, Dumont T, Kan P, Kim JT, De Leacy R, Maier I, Osbun J, Rai A, Jabbour P, Grossberg JA, Park MS, Starke RM, Crosa R, Spiotta AM. Outcomes of Rescue Endovascular Treatment of Emergent Large Vessel Occlusion in Patients With Underlying Intracranial Atherosclerosis: Insights From STAR. J Am Heart Assoc 2021; 10:e020195. [PMID: 34096337 PMCID: PMC8477850 DOI: 10.1161/jaha.120.020195] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Some emergent large vessel occlusions (ELVOs) are refractory to reperfusion because of underlying intracranial atherosclerosis (ICAS), often requiring rescue therapy (RT) with balloon angioplasty, stenting, or both. In this study, we investigate the safety, efficacy, and long‐term outcomes of RT in the setting of mechanical thrombectomy for ICAS‐related ELVO. Methods and Results We queried the databases of 10 thrombectomy‐capable centers in North America and Europe included in STAR (Stroke Thrombectomy and Aneurysm Registry). Patients with ELVO who underwent ICAS‐related RT were included. A matched sample was produced for variables of age, admission National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, onset to groin puncture time, occlusion site, and final recanalization. Out of 3025 patients with MT, 182 (6%) patients required RT because of underlying ICAS. Balloon angioplasty was performed on 122 patients, and 117 patients had intracranial stenting. In the matched analysis, 141 patients who received RT matched to a similar number of controls. The number of thrombectomy passes was higher (3 versus 1, P<0.001), and procedural time was longer in the RT group (52 minutes versus 36 minutes, P=0.004). There was a higher rate of symptomatic hemorrhagic transformation in the RT group (7.8% versus 4.3%, P=0.211), however, the difference was not significant. There was no difference in 90‐day modified Rankin scale of 0 to 2 (44% versus 47.5%, P=0.543) between patients in the RT and control groups. Conclusions In patients with ELVO with underlying ICAS requiring RT, despite longer procedure time and a more thrombectomy passes, the 90 days favorable outcomes were comparable with patients with embolic ELVO.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology Medical University of South Carolina Charleston SC.,Department of Neurosurgery Medical University of South Carolina Charleston SC
| | - Eyad Almallouhi
- Department of Neurology Medical University of South Carolina Charleston SC.,Department of Neurosurgery Medical University of South Carolina Charleston SC
| | - Ali Alawieh
- Department of Neurosurgery Emory University School of Medicine Atlanta GA
| | - Stacey Wolfe
- Department of Neurosurgery Wake Forest School of Medicine Winston Salem NC
| | - Kyle M Fargen
- Department of Neurosurgery Wake Forest School of Medicine Winston Salem NC
| | - Adam S Arthur
- Department of Neurosurgery Semmes-Murphey Neurologic and Spine Clinic University of Tennessee Health Science Center Memphis TN
| | - Nitin Goyal
- Department of Neurosurgery Semmes-Murphey Neurologic and Spine Clinic University of Tennessee Health Science Center Memphis TN.,Department of Neurology University of Tennessee Health Science Center Memphis TN
| | - Travis Dumont
- Department of Neurosurgery University of Arizona Health Sciences Tucson AZ
| | - Peter Kan
- Department of Neurosurgery Baylor School of Medicine Houston TX
| | - Joon-Tae Kim
- Department of Neurology Chonnam National University Hospital Seoul South Korea
| | - Reade De Leacy
- Department of Neurosurgery Mount Sinai Health System New York NY
| | - Ilko Maier
- Department of Neurology University Medical Center Göttingen Göttingen Germany
| | - Joshua Osbun
- Department of Neurosurgery Washington University of School of Medicine St. Louis MO
| | - Ansaar Rai
- Department of Radiology West Virginia School of Medicine Morgantown WV
| | - Pascal Jabbour
- Department of Neurosurgery Thomas Jefferson University Hospitals Philadelphia PA
| | | | - Min S Park
- Department of Neurosurgery University of Virginia Charlottesville VA
| | - Robert M Starke
- Department of Neurosurgery University of Miami Health System Miami FL
| | - Roberto Crosa
- Department of Neurosurgery Endovascular Neurological Center Médica Uruguaya Montevideo Uruguay
| | - Alejandro M Spiotta
- Department of Neurosurgery Medical University of South Carolina Charleston SC
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34
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Al Kasab S, Almallouhi E, Alawieh A, Jabbour P, Sweid A, Starke RM, Saini V, Wolfe SQ, Fargen KM, Arthur AS, Goyal N, Pandhi A, Maier I, Grossberg JA, Howard BM, Tjoumakaris SI, Rai A, Park MS, Mascitelli JR, Psychogios MN, Spiotta AM. Alarming downtrend in mechanical thrombectomy rates in African American patients during the COVID-19 pandemic-Insights from STAR. J Neurointerv Surg 2021; 13:304-307. [PMID: 33408256 PMCID: PMC8895862 DOI: 10.1136/neurintsurg-2020-016946] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/11/2020] [Accepted: 12/12/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND The coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT). METHODS We used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020). RESULTS We identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004). CONCLUSION The COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.
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Affiliation(s)
- Sami Al Kasab
- Neurosurgery, Medical University of South
Carolina, Charleston, SC, USA
- Neurology,
Medical University of South Carolina, Charleston, SC, USA
| | | | - Eyad Almallouhi
- Neurosurgery, Medical University of South
Carolina, Charleston, SC, USA
- Neurology,
Medical University of South Carolina, Charleston, SC, USA
| | - Ali Alawieh
- Neurosurgery, Emory University, Atlanta, GA,
USA
- Microbiology and
Immunology, Medical University of South Carolina,
Charleston, SC, USA
| | - Pascal Jabbour
- Neurological
Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
| | - Ahmad Sweid
- Neurological
Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
| | - Robert M Starke
- Neurological
Surgery, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Vasu Saini
- Neurological
Surgery, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine,
Winston-Salem, NC, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, NC, USA
| | - Adam S Arthur
- Neurosurgery, Semmes-Murphey Neurologic and Spine
Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science
Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Neurosurgery, University of Tennessee Health Science
Center, Memphis, Tennessee, USA
| | - Abhi Pandhi
- Neurology, University of Tennessee Health Science Center
College of Medicine, Memphis,
Tennessee, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen,
Goettingen, NS, Germany
| | - Jonathan A Grossberg
- Neurosurgery and
Radiology, Emory University School of Medicine,
Atlanta, Georgia, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of
Medicine, Atlanta, Georgia, USA
- Radiology and Imaging
Sciences, Emory University School of Medicine,
Atlanta, Georgia, USA
| | | | - Ansaar Rai
- Radiology, West Virginia University Hospitals,
Morgantown, West Virginia, USA
| | - Min S Park
- Neurosurgery, Barrow Neurological Institute,
Phoenix, Arizona, USA
| | - Justin R Mascitelli
- Neurosurgery, University of Texas Health Science Center at San
Antonio, San Antonio, Texas, USA
| | - Marios N Psychogios
- Department of
Neuroradiology, Clinic of Radiology and Nuclear Medicine,
University Hospital Basel, Basel, Switzerland
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35
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Almallouhi E, Al Kasab S, Alawieh A, Al-Kawaz M, Starke R, Grossberg JA, Jabbour PM, Wolfe S, Fargen K, Levitt M, Arthur AS, De Leacy RA, Park MS, Raper D, Polifka A, Crowley RW, Dumont T, Osbun J, Crosa R, Maier I, Kim JT, Casagrande W, Rai A, Chowdhry S, Mokin M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios M, Hui FK, Spiotta AM. Abstract P504: Outcomes and Predictors of Successful First Pass in MCA Occlusions Using ADAPT Thrombectomy Technique - Insights From STAR. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p504] [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:
Successful first pass (SFP) has been identified as a key benchmark of the success of mechanical thrombectomy (MT). However, studies that evaluate the predictors and outcomes of SFP using ADAPT (A Direct Aspiration first Pass Technique) are limied by the small number of patients or single center design.
Methods:
We used data from the prospectively collected data from 28 stroke centers that are included in the Stroke Thrombectomy and Aneurysm Registry (STAR). Patients with middle cerebral artery (MCA) occlusions at the level of M1 or M2 segments were included. SFP was defined by achieving modified Thrombolysis in Cerebral Infarction (mTICI) score≥2b with a single aspiration attempt. A multivariable logistic regression analysis was used to assess the predictors of SFP and evaluate the relationship between SFP and favorable 90-day outcome (90-day modified Rankin scale ≤2).
Results:
Out of 6123 patients included in STAR, 1002 (16.4%) underwent MT of M1 or M2 occlusion using ADAPT technique. SFP was achieved in 390 (38.9%) patients. SFP patients were older (72 vs. 69, P=0.007), had higher Alberta Stroke Program Early CT Score (ASPECTS) on presentation (9 vs. 8, P=0.018) (Table 1). On multivariable analysis, neither age (aOR 1.006, 95% CI 0.996-1.016, P=0.252) nor ASPECTS (aOR 1.055, 95% CI 0.976-1.141, P=0.179) were independent predictor of SFP. Importantly, SFP was independently associated with favorable 90-day outcome (aOR 2.769, 95% CI 1.988-3.858, P<0.001) after controlling for age, sex, ASPECTS, history of atrial fibrillation, NIHSS on presentation, onset to groin time and IV-tPA.
Conclusion:
In this cohort of patients with M1 or M2 occlsuion undergoing MT using ADAPT technique, patients who had SFP were older and had better ASPECTS. However, both age and ASPECTS were not independently associated with SFP. Also, patients who had SFP were almost 3 times more likely to achieve favorable 90-day outcome.
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Affiliation(s)
| | | | - Ali Alawieh
- Med Univ of South Carolina, MOUNT PLEASANT, SC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joon-tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
| | - Walter Casagrande
- Sanatorio Goemes and Hosp of Agudos Juan A Fernadez, Argentina, Argentina
| | | | | | | | | | | | | | | | | | - Peter Kan
- The Univ of Texas Med Branch, Galveston, TX
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Porto GB, Hubbard Z, Al Kasab S, Almallouhi E, Starke R, De Leacy RA, Raper D, Rai A, Dumont T, Wolfe S, Jabbour P, Ogilvy CS, Park MS, Levitt M, Polifka A, Crowley R, Arthur AS, Osbun J, Crosa R, Maier I, Kim JT, Casagrande W, Grossberg JA, Chowdhry S, Mokim M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios MN, Spiotta AM. Abstract P11: Clinical Utility of Aspects in Late Window Stroke Thrombectomy Patients: Insights From Star. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p11] [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:
Recent trials have proven safety and efficacy of mechanical thrombectomy for patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset. While evidence supports using baseline CT scan to evaluate the candidacy for mechanical thrombectomy for patients presenting in the early window, late window trials have used advanced imaging such as CT and MR perfusion. We aim to assess outcomes of MT stratified by admission Alberta Stroke Program Early CT Score (ASPECTS).
Methods:
We used data from the prospectively maintained registries of 28 stroke centers in the Stroke Thrombectomy and Aneurysm (STAR) collaboration. Demographics, comorbidities, LVO site, ASPECTS, MT technique, radiographic and clinical outcome data were collected. Patients with M1 or ICA occlusion were included in these analyses. Multivariable analysis was performed using a generalized linear model with logit link to assess for variables associated with favorable outcomes.
Results:
3356 patients in the STAR database were reviewed and 347 (10.3%) of those underwent MT in the late window (table). Median age was 69, 189 (54.5%) were female, and 181 (52.2%) were white. 295 patients ASPECTS ≥6. In this group, 200 (68.8%) had M1 occlusion, and the remaining had ICA occlusion. Aspiration thrombectomy was used in 139 (47.1%) of patients. Successful reperfusion was achieved (mTICI≥2b) in 264 (76.1%). sICH was observed in 15 (5.1%). Excellent functional outcome (mRS 0-2) was observed in 124 (42%) patients. ASPECTS score was independently associated with favorable outcomes (aOR 1.2, 95% CI 1.1-1.4, P=0.006).
Conclusion:
Excellent outcomes are observed in patients with good ASPECT score presenting in the late window irrespective of perfusion criteria. Admission CT scan could be used to triage patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joon Tae Kim
- Chonnam National Univ Hosp, NA, Korea, Republic of
| | | | | | | | | | | | | | | | | | | | - Peter Kan
- Univ of Texas Med Branch at Galveston, Galveston, TX
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37
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Almallouhi E, Al Kasab S, Alawieh A, Chen S, BURKS JOSHUA, Wolfe S, Jabbour PM, Levitt M, Arthur AS, De Leacy RA, Grossberg JA, Ogilvy CS, Park MS, Raper D, Polifka A, Crowley RW, Dumont T, Osbun J, Crossa R, Maier I, Kim JT, Casagrande W, Rai A, Chowdhry S, Mokin M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios M, Fargen K, Starke R, Spiotta AM. Abstract P6: Impact of Ethnicity on the Outcomes of Mechanical Thrombectomy- Insights From Star. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p6] [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:
Previous studies have reported that Hispanic stroke patients have limited access to mechanical thrombectomy (MT) compared to other ethnic groups. This has resulted in worse stroke outcomes in this group. However, limited data is available about the outcomes of MT in Hispanic patients.
Methods:
We used data from the Stroke Thrombectomy and Aneurysm Registry (STAR) that combined the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. Consecutive patients who underwent MT were included in these analyses and patients were divided into 2 groups (Hispanics vs. non-Hispanics). Baseline features, time from symptom onset, thrombolysis receipt, final thrombolysis in cerebral infarction (TICI) score, symptomatic hemorrhage, and 90-day functional outcomes (measured by modified Rankin scale-mRS) were compared between Hispanic and non-Hispanics patients. A generalized linear model with logit link was used to assess the relationship between ethnicity and favorable outcomes at 90-day (mRS 0-2) controlling for confounders.
Results:
We included 2015 patients in these analyses. Of those, 285 (14.1%) were Hispanic. As shown in table 1, Hispanic patients were older (72 vs. 70, p=0.007), more likely to have diabetes (41.1% vs. 26.5%, p<0.001), and more likely to have hypertension (81.8% vs. 73.7%, p=0.004). Importantly, Hispanics had a shorter procedure duration with a similar rate of successful recanalization (TICI≥2B). On multivariable analysis, Hispanic ethnicity was associated with a lower probability of favorable 90-day outcome (aOR 0.659, 95% CI 0.494-0.879, P=0.005) after controlling for age, stroke risk factors and location of occlusion.
Conclusion:
Hispanic patients receiving MT have higher rate of stroke risk factors including diabetes and hypertension. Moreover, Hispanic ethnicity was independently associated with lower probability of favorable 90-day outcome.
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Affiliation(s)
| | | | - Ali Alawieh
- Med Univ of South Carolina, MOUNT PLEASANT, SC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
| | - Walter Casagrande
- Sanatorio Goemes and Hosp of Agudos Juan A Fernadez, Argentina, Argentina
| | | | | | | | | | | | | | | | | | - Peter Kan
- The Univ of Texas Med Branch, Galveston, TX
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38
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Hubbard Z, Porto GB, Al Kasab S, Almallouhi E, Spiotta AM, De Leacy RA, Raper D, rai A, Dumont T, Wolfe S, Jabbour PM, Ogilvy CS, Park MS, Levitt M, Polifka A, Crowley R, Arthur AS, Osbun J, Crosa R, Maier I, Kim JT, Casagrande W, Grossberg JA, Chowdhry SA, Mokin M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios MN, Starke R. Abstract P500: Outcomes of Mechanical Thrombectomy in Patients With Low Aspects: Insights From Star. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p500] [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:
Patients with poor baseline images were excluded from most clinical trials so the data about whether these patients could benefit from MT remains unknown. In this study, we aim to investigate the safety and efficacy of MT in patients with large vessel occlusion (LVO) and large core infarct (LCI).
Methods:
The Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We included thrombectomy patients presenting with LVO within 24 hours and with a LCI as defined by Alberta Stroke Program Early CT Score (ASPECTS) < 6. Patients presenting within 6 hours of last known normal (LKN) were considered in the early window and patients presenting after 6 hours were considered in the late window. 90-day outcomes were assessed. We used a logistic regression model to assess the factors associated with good 90-day outcome in patients in the early and late windows.
Results:
144 patients were included in this study (table). Median age was 69 and 92 (64%) patients were treated in the early MT window. ICA was the most common site of occlusion (48.6%) and ADAPT was used in 34.7%. Admission NIHSS was 17.5. Successful recanalization (TICI>2b) was achieved in 84.7% and median procedure time was 54 minutes. sICH hemorrhage was observed in 22 (15.3%). Median mRS was 4 at 90 days. Favorable outcome was observed in 41 patients (28.5%) and mortality occurred in in 59 (41%). There was no difference in 90-day functional outcome between patients in early and late windows. In patients presenting in the early window, age (aOR=0.905, p=0.0002) and baseline NIHSS (aOR=0.909, p=0.0423) were independently associated with 90-day outcome. In patients presenting in the late window, only age (aOR=0.934, p=0.0069) was independently associated with good outcome.
Conclusion:
More than one in four patients presenting with ASPECTS<6 may achieve functional independence at 90-day following MT. Patient age remains the main predictor of 90-day outcome in patients with low ASPECTS in both late and early windows.
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Affiliation(s)
- Zachary Hubbard
- Dept of Neurosurgery, Med Univ of South Carolina, Charleston, SC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ilko Maier
- Dept of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
| | | | | | | | | | | | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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39
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Akbik F, Alawieh A, Cawley CM, Howard B, Tong F, Nahab FB, Saad H, Dimisko L, Mustroph CM, Pradilla G, Maier I, Goyal N, Starke R, rai A, Fargen K, Psychogios M, Jabbour PM, De Leacy RA, Keyrouz SG, Dumont T, Kan P, Arthur AS, Crosa R, Gory B, Spiotta AM, Grossberg JA. Abstract P20: Bridging Therapy Increases Hemorrhagic Complications Without Improving Functional Outcomes in Atrial Fibrillation Associated Stroke. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
*
on behalf of the Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators
Introduction:
Intravenous thrombolysis complications are enriched in AF associated stroke, as these patients have worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications. These data suggest that AF patients may be at particularly high risk for complications of bridging therapy for large vessel occlusions treated with mechanical thrombectomy (MT). Here we determine whether clinical outcomes differ in AF associated stroke treated with MT and bridging therapy.
Methods:
We performed a retrospective cohort study of the Stroke and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4,169 patients who underwent MT for an anterior circulation stroke, 1,517 (36.4 %) of which had comorbid AF. Prospectively defined baseline characteristics and clinical outcomes were compared.
Results:
Hemorrhagic complications after MT were similar in patients with or without AF. In patients without AF, bridging therapy improved 90-day outcomes (aOR 1.32, 1.02-1.74, p<0.05) without increasing hemorrhagic complications. In patients with AF, bridging therapy independently predicted hemorrhagic complications in AF patients (aOR 2.08, 1.06-4.06, p<0.033) without improving functional outcomes.
Conclusions:
Bridging therapy in AF patients undergoing thrombectomy independently increased the odds of intracranial hemorrhage and did not improve functional outcomes. AF patients may represent a high-risk subgroup for thrombolytic complications. Randomized trials are warranted to determine whether patients with AF associated stroke may benefit by deferring bridging therapy at thrombectomy-capable centers.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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Prasad A, Kobsa J, Kodali S, Nguyen CK, Quispe Orozco D, Farooqui M, Zevallos C, Ortega S, Anadani M, Almallouhi E, Giles JA, Spiotta AM, Kim JT, Maier I, Psychogios M, Liman J, Riou-Comte N, Richard S, Gory B, Wolfe S, Brown PA, Fargen K, Mistry E, Fakhri H, Mistry A, Wong KH, De Havenon AH, Nascimento F, Kan P, Sheth KN, Petersen NH. Abstract MP33: Association Between Neurologic Outcomes and Temporal Profile of Systolic Blood Pressure Variability After Endovascular Thrombectomy. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.mp33] [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:
Higher systolic blood pressure variability (BPV) after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and worse functional outcomes. However, the time-varying behavior of BPV after EVT and its effects on functional outcome have not been well characterized.
Methods:
We analyzed data from an international cohort of patients with acute large-vessel occlusion stroke who underwent EVT at 11 centers across North America, Europe, and Asia. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Parameters of BPV were calculated in 12-hour epochs using five established methodologies: standard deviation (SD), coefficient of variation (CV), average real variability (ARV), successive variation (SV), and residual SD (rSD). Patients’ overall mean BPV was then used to assign patients into tertiles for regression analysis: low BPV, intermediate BPV, and high BPV. Functional outcome was measured with the modified Rankin Scale (mRS) at 90 days.
Results:
Of the 1,791 patients (age 69 ± 14, NIHSS 15 ± 6) included in our analysis, 1,085 (60.6%) had a poor 90-day outcome (mRS >3). Patients with poor outcome had significantly higher systolic BPV (p<0.05) measured as standard deviation (SBP SD) at each epoch (Figure 1B). Compared to patients with low BPV, those in the highest tertile group had significantly greater odds of a poor functional outcome after adjusting for age, sex, hypertension, NIHSS, ASPECT, tPA, time to reperfusion, and TICI score (OR 1.5; 95% CI 1.2-2; p=0.001). Patients in the highest tertile of BPV demonstrated time-dependent variability with the highest SBP SD during the first 24 hours after thrombectomy (Figure 1A).
Conclusions:
Higher BPV measured by SBP SD appears to be associated with poor 90-day outcome in EVT-treated stroke patients. Early treatment strategies targeting early high BPV warrant further prospective investigation.
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Affiliation(s)
- Ayush Prasad
- Div of Neurocritical Care and Emergency Neurology, Yale Univ Sch of Medicine, New Haven, CT
| | | | | | | | | | | | | | | | | | | | - James A Giles
- Dept of Neurology, Washington Univ Sch of Medicine, St. Louis, MO
| | | | | | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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41
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Grossberg J, Eshraghi S, Howard B, Buster B, Akbik F, Maier I, Goyal N, Starke R, rai A, Fargen K, Psychogios M, Jabbour PM, De Leacy RA, Keyrouz SG, Dumont T, Kan P, Arthur AS, Crosa R, Gory B, Spiotta AM. Abstract P479: A Tale of Two Clots: A Multicenter Study on Multiple Territory Thrombectomy. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p479] [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:
The benefit of thrombectomy for large vessel occlusion (LVO) is well proven. There is minimal data on concurrent thrombectomy for multi-territory occlusions.
Methods:
We reviewed the STAR registry from 2015-8 for patients treated with either right and left sided thrombectomy or anterior and posterior circulation thrombectomy at 15 comprehensive stroke centers.
Results:
There were 4966 patients in the study period who had completed outcome data and LVO thrombectomy. 38 (0.8%) underwent endovascular thrombectomy for multi-territory occlusions. 26% had bilateral occlusions and 74% had anterior and posterior circulation occlusions. Among the 38, 50% were female, 49% were white, and 91% had a prestroke mRS<3. 95% had an ASPECT score of >6 and 55% received iv t-pa. 83% of patients had successful recanalization (TICI 2B/3) for both territories. The overall complication rate was 15%. 5% of patients had sICH or PH2. 26% of patients had a 90day mRS<2. When controlling for admission NIHSS, baseline mRS, age, comorbidities, and ASPECT in logistic regression analysis, multiple territory compared to single territory did not predict increased risk of sICH (p=0.73, 95%CI: 0.2-3.3), rate of TICI2B/3 (OR for TICI2B+: 0.93, p=0.88, CI: 0.38 - 2.3), or worse outcome (OR for good outcome: 0.6, p=.212, CI: 0.3-1.3). On linear regression analysis for attempts and procedure time, multiple territory thrombectomy required significantly higher number of attempts (Coefficient +1.8, p=0.001) without a significantly longer procedure time (Coefficient = +10, p=0.244).
Conclusion:
With similar selection to single territory LVOs, good outcome can be achieved in multi-territory infarction with reasonable procedure time and no additional risk of hemorrhage or poor outcome.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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42
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Akbik F, Alawieh A, Cawley CM, Howard BM, Tong FC, Nahab F, Saad H, Dimisko L, Mustroph C, Samuels OB, Pradilla G, Maier I, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios MN, Jabbour P, De Leacy R, Giles J, Dumont TM, Kan P, Arthur AS, Crosa RJ, Gory B, Spiotta AM, Grossberg JA. Differential effect of mechanical thrombectomy and intravenous thrombolysis in atrial fibrillation associated stroke. J Neurointerv Surg 2020; 13:883-888. [PMID: 33318066 DOI: 10.1136/neurintsurg-2020-016720] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/17/2020] [Accepted: 10/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT). OBJECTIVE To determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT. METHODS We performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared. RESULTS AF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (p<0.01). AF had no effect on intracranial hemorrhage (aOR 0.69, 95% CI 0.43 to 1.12) or 90-day functional outcomes (aOR 1.17, 95% CI 0.91 to 1.50) after MT, although patients with AF were less likely to receive IVT (46% vs 54%, p<0.0001). CONCLUSIONS In patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.
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Affiliation(s)
- Feras Akbik
- Department of Neurology, Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Frank C Tong
- Department of Radiology, Emory University, Altanta, Georgia, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | | | - Owen B Samuels
- Department of Neurology, Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami Beach, Florida, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Giles
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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43
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Alawieh A, Al Kasab S, Almallouhi E, Levitt MR, Jabbour PM, Sweid A, Starke RM, Saini V, Fargen KM, Wolfe SQ, Arthur AS, Goyal N, Fragata I, Maier I, Matouk C, Howard BM, Grossberg JA, Cawley M, Kan P, Hafeez M, Singer J, Crowley RW, Joshi KC, Brinjikji W, Savastano LE, Ogilvy CS, Gomez-Paz S, Levy E, Waqas M, Mokin M, Veznedaroglu E, Binning M, Mascitelli J, Yoo AJ, Soomro J, Williamson RW, Chalhoub RM, Grande A, Crosa R, Webb S, Psychogios M, Ducruet AF, Albuquerque FC, Majmundar N, Turner R, Casagrande W, Al-Mufti F, De Leacy R, Mocco J, Fessler RD, Osanai T, Chowdhry SA, Park M, Schirmer CM, Ringer A, Spiotta AM. Letter: An International Investigation Into the COVID-19 Pandemic and Workforce Depletion in Highly Specialized Neurointerventional Units - Insights From Stroke Thrombectomy and Aneurysm Registry and Endovascular Neurosurgery Research Group. Neurosurgery 2020; 87:E697-E699. [PMID: 32893855 PMCID: PMC7499731 DOI: 10.1093/neuros/nyaa415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/26/2023] Open
Affiliation(s)
- Ali Alawieh
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia
| | - Sami Al Kasab
- Department of Neurosurgery Medical University of South Carolina Charleston, South Carolina.,Department of Neurology Medical University of South Carolina Charleston, South Carolina
| | - Eyad Almallouhi
- Department of Neurology Medical University of South Carolina Charleston, South Carolina
| | - Michael R Levitt
- Department of Neurosurgery University of Washington Seattle, Washington
| | - Pascal M Jabbour
- Department of Neurosurgery Thomas Jefferson University Hospitals Philadelphia, Pennsylvania
| | - Ahmad Sweid
- Department of Neurosurgery Thomas Jefferson University Hospitals Philadelphia, Pennsylvania
| | - Robert M Starke
- Department of Neurosurgery University of Miami Health System Miami, Florida
| | - Vasu Saini
- Department of Neurosurgery University of Miami Health System Miami, Florida
| | - Kyle M Fargen
- Department of Neurosurgery Wake Forest School of Medicine Winston Salem, North Carolina
| | - Stacey Q Wolfe
- Department of Neurosurgery Wake Forest School of Medicine Winston Salem, North Carolina
| | - Adam S Arthur
- Department of Neurosurgery Semmes-Murphey Neurologic and Spine Clinic University of Tennessee Health Science Center Memphis, Tennessee
| | - Nitin Goyal
- Department of Neurosurgery Semmes-Murphey Neurologic and Spine Clinic University of Tennessee Health Science Center Memphis, Tennessee.,Department of Neurology University of Tennessee Health Science Center Memphis, Tennessee
| | - Isabel Fragata
- Neuroradiology Department Hospital São José Centro Hospitalar Lisboa Central Lisboa, Portugal
| | - Ilko Maier
- Department of Neurology University Medical Center Göttingen Göttingen, Germany
| | - Charles Matouk
- Department of Neurosurgery Yale University/Yale-New Haven Hospital New Haven, Connecticut
| | - Brian M Howard
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia
| | | | - Michael Cawley
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia
| | - Peter Kan
- Department of Neurosurgery Baylor School of Medicine Houston, Texas
| | - Muhammad Hafeez
- Department of Neurosurgery Baylor School of Medicine Houston, Texas
| | - Justin Singer
- Division of Neurosurgery Spectrum Health Grand Rapids, Michigan
| | | | - Krishna C Joshi
- Department of Neurosurgery Rush University Chicago, Illinois
| | | | | | | | - Santiago Gomez-Paz
- Department of Neurosurgery Beth Israel Deaconess Hospital Boston, Massachusetts
| | - Elad Levy
- Department of Neurosurgery University at Buffalo Buffalo, New York
| | - Muhammad Waqas
- Department of Neurosurgery University at Buffalo Buffalo, New York
| | - Maxim Mokin
- Department of Neurosurgery University of South Florida Tampa, Florida
| | | | - Mandy Binning
- Global Neurosciences Institute Pennington, New Jersey
| | - Justin Mascitelli
- Department of Neurosurgery University of Texas Health Science Center at San Antonio San Antonio, Texas
| | | | | | | | - Reda M Chalhoub
- Department of Neurosurgery Medical University of South Carolina Charleston, South Carolina
| | - Andrew Grande
- Department of Neurosurgery University of Minnesota Minneapolis, Minnesota
| | - Roberto Crosa
- Department of Neurosurgery Centro Endovascular Neurologico Medica Uruguaya Montevideo, Uruguay
| | - Sharon Webb
- Department of Neurosurgery Bon Secours Greenville, South Carolina
| | | | - Andrew F Ducruet
- Department of Neurosurgery Barrow Neurological Institute Phoenix, Arizona
| | | | - Neil Majmundar
- Department of Neurosurgery Barrow Neurological Institute Phoenix, Arizona
| | | | - Walter Casagrande
- Department of Cerebrovascular and Endovascular Neurosurgery Hospital Juan Fernandez Buenos Aires, Argentina
| | - Fawaz Al-Mufti
- Department of Neurosurgery and Radiology Westchester Medical Center New York, New York
| | - Reade De Leacy
- Department of Neurosurgery Mount Sinai Health System New York, New York
| | - J Mocco
- Department of Neurosurgery Mount Sinai Health System New York, New York
| | | | | | - Shakeel A Chowdhry
- Department of Neurosurgery NorthShore University Health System Evanston, Illinois
| | - Min Park
- Department of Neurosurgery University of Virginia Charlottesville, Virginia
| | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute Geisinger Health System Wilkes-Barre, Pennsylvania.,Research Institute of Neurointervention Paracelsus Medical University Salzburg, Austria
| | - Andrew Ringer
- Department of Neurosurgery Mayfield Brain & Spine Cincinnati, Ohio
| | - Alejandro M Spiotta
- Department of Neurosurgery Medical University of South Carolina Charleston, South Carolina
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44
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Al Kasab S, Almallouhi E, Alawieh A, Levitt MR, Jabbour P, Sweid A, Starke RM, Saini V, Wolfe SQ, Fargen KM, Arthur AS, Goyal N, Pandhi A, Fragata I, Maier I, Matouk C, Grossberg JA, Howard BM, Kan P, Hafeez M, Schirmer CM, Crowley RW, Joshi KC, Tjoumakaris SI, Chowdry S, Ares W, Ogilvy C, Gomez-Paz S, Rai AT, Mokin M, Guerrero W, Park MS, Mascitelli JR, Yoo A, Williamson R, Grande AW, Crosa RJ, Webb S, Psychogios MN, Ducruet AF, Holmstedt CA, Ringer AJ, Spiotta AM. International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG. J Neurointerv Surg 2020; 12:1039-1044. [PMID: 32843359 PMCID: PMC7453763 DOI: 10.1136/neurintsurg-2020-016671] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. METHODS A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. RESULTS 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). CONCLUSION We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.
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Affiliation(s)
- Sami Al Kasab
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ali Alawieh
- Neurosurgery, Emory University, Atlanta, Georgia, USA.,Microbiology and Immunology, Medical University of South Carolina, South Carolina, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami Beach, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Vasu Saini
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Abhi Pandhi
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Muhammad Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Krishna C Joshi
- Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Shakeel Chowdry
- North Shore University Health System, Evanston, Illinois, USA
| | - William Ares
- Neurosurgery, North Shore University Health System, Evanston, Illinois, USA
| | | | | | - Ansaar T Rai
- Department of Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Waldo Guerrero
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Min S Park
- Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Justin R Mascitelli
- Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Albert Yoo
- Texas Stroke Institute, Fort Worth, Texas, USA
| | - Richard Williamson
- Stroke & Cerebrovascular Center, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Andrew Walker Grande
- Neurosurgery, Radiology and Neurology, University of Minnesota, Mendota Heights, Minnesota, USA
| | | | - Sharon Webb
- Neurosurgery, Bon Secours St Francis Hospital, Greenville, South Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Andrew J Ringer
- Neurosurgery, Mayfield Clinic, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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45
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Alawieh AM, Chowdhry S, Linfante I, Grossberg J, Gory B, Shaban A, Crosa R, Shah S, Crowley R, Knopman J, Fox C, Levitt M, Ducruet A, Park M, Ogilvy CS, Jabbour P, Arthur A, Arthur A, Kim JT, De Leacy R, Psychogios M, Maier I, Rai A, Keyrouz S, Fargen K, Dumont T, Kan P, Starke RM, Spiotta A. Abstract WP32: Introducing STAR: A Multicenter International Collaborative Registry of Real-World Outcomes After Mechanical Thrombectomy for Ischemic Stroke. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Mechanical thrombectomy (MT) for acute stroke is the current standard of care treatment. Level 1 evidence for efficacy of thrombectomy has been established in multiple randomized controlled trials on selective patient populations; however, the high effect size of MT had led multiple centers in the US and globally to expand their patient selection to include populations that were not studied in major trials. To provide ongoing data on MT outcomes in different patient populations from the real-world, we have initiated an international multicenter initiative, STAR (Stroke Thrombectomy and Aneurysm Registry).
Methods:
STAR is a multicenter and international platform to curate patient outcome data after MT for acute ischemic stroke at comprehensive stroke centers. STAR includes all patients who underwent MT for acute ischemic stroke irrespective of age, time from onset, ASPECT score, and NIHSS. Patients were curated from 01/2015 to date and is prospectively maintained. Patient charts are reviewed for demographics, baseline functioning, and admission deficits. Procedure notes are reviewed for technical variables and technical outcomes. Clinical outcomes were collected at 90-day follow-up by stroke neurologist.
Results:
A total of 24 centers globally have enrolled in STAR. By December 2018, the total number of enrolled and verified patients in STAR was 3,850 (mean age 69±14, 51% females). Anterior circulation strokes were treated in 89% of cases, average NIHSS on admission was 15.5±7, and 73% had pre-stroke mRS below 2. Around 51% of patients received IV-tPA. Mechanical thrombectomy was performed using aspiration (45%), stent retriever (28%), primary combined approach (24%) or intracranial stenting (3%). Successful recanalization was achieved in 84% of cases, the rate of favorable outcome (mRS 0-2) was 41%, and mortality was 25%. Complication rate was 6% and rate of symptomatic post-procedural hemorrhage was 6%.
Conclusions:
STAR represent a large real-world international registry for outcomes after MT, and constitutes a statistically robust platform to study real-world practice outcome in patient sub-populations that are under-represented in randomized trials.
Link:
https://medicine.musc.edu/departments/neurosurgery/star
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Min Park
- Univ of Virginia, Charlottesville, VA
| | | | | | - Adam Arthur
- The Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Adam Arthur
- The Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Joon-Tae Kim
- Chonnam National Univ Hosp, Kwangju, Korea, Republic of
| | | | | | - Ilko Maier
- Universitätsmedizin Göttingen, Göttingen, Germany
| | | | | | - Kyle Fargen
- Wake Forest Baptist Health, Winston-Salem, NC
| | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
| | - Robert M Starke
- Univ of Miami Health System, Univ of Miami Health System, FL
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46
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Alawieh AM, Alawieh MB, Zaraket F, Chalhoub RM, Anadani M, Keyrouz S, Arthur A, Kim JT, De Leacy R, Psychogios M, Maier I, Rai A, Fargen K, Dumont T, Kan P, Starke RM, Spiotta A. Abstract 150: Multicenter Validation of SPOT, an Artificial Intelligence Based Tool, to Optimize Selection of Elderly Stroke Patients for Mechanical Thrombectomy - Insights From the STAR Collaboration. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.150] [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:
Mechanical thrombectomy for acute ischemic stroke (AIS) is the current standard of care based on level 1 evidence from multiple randomized controlled trials. Recently, real-world indications for mechanical thrombectomy (MT) has extended beyond the inclusion criteria used in the majority of trials including elderly patients. We have recently developed a machine-learning based tool, SPOT, to optimize selection of elderly patients for MT based on single-center data. Here, we use a large cohort of international multicenter patients who underwent MT for AIS to externally validate SPOT.
Methods:
Patients who underwent MT for AIS at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Patients age 80 years or older were included for validation of SPOT. SPOT is designed based on a combination of decision trees and linear regression models to provide binary output of predicted good (mRS 0-2) or poor outcome (mRS 3-6) after MT. SPOT uses admission variables: age, gender, comorbidities, admission NIHSS, baseline mRS score, ASPECT score and whether IV-tPA was administered. Predicted outcome was compared to actual outcome recorded at 90-days after treatment. A receiver operating characteristic curve was used to evaluate the accuracy of SPOT, and the negative predictive value was computed. The rate of post-procedural hemorrhage and mortality were compared between patients predicted by SPOT to have good versus poor outcome.
Results:
A total of 3,228 patients underwent MT for AIS during the study duration, of which 647 patients were at least 80 years of age or older and were included in the study. The average age was 85±5 years, and 65% were females. The median mRS score at 90 days was 4, and 21.3% had a good outcome (mRS 0-2). Of patients predicted by SPOT to have a poor outcome, 90% had a poor outcome. The area under the ROC curve was 0.7. The mortality rate in patients predicted by SPOT to have poor outcome had twice higher mortality than those predicted to have good outcome (55% vs 27%, p<0.001).
Conclusions:
Based on multicenter validation, SPOT presents a clinical decision in aid in assisting for exclusion of elderly patients unlikely to benefit from MT for AIS with a 90% negative predictive value.
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Affiliation(s)
| | | | | | | | | | | | - Adam Arthur
- The Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Joon-Tae Kim
- Chonnam National Univ Hosp, Kwangju, Korea, Democratic People’s Republic of
| | | | | | - Ilko Maier
- Universitätsmedizin Göttingen, Göttingen, Germany
| | | | - Kyle Fargen
- Wake Forest Baptist Health, Winston-Salem, NC
| | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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47
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Alawieh AM, Chalhoub R, Anadani M, Eid M, Almallouhi E, Arthur A, Kim JT, De Leacy R, Psychogios M, Maier I, Rai A, Grossberg J, Keyrouz S, Fargen K, Dumont T, Kan P, Starke RM, Spiotta A. Abstract WP26: Use of Balloon-guide Catheter Bridges the Difference in Technical Outcomes Between Adapt and Stent Retriever Thrombectomy for Ischemic Stroke - Insights From STAR Collaboration. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp26] [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:
Recently completed randomized controlled trials comparing aspiration thrombectomy (ADAPT) to stent retriever thrombectomy (SRT) demonstrated similar clinical outcomes, but faster thrombectomy procedure time in the ADAPT group. This study evaluates the difference in technical outcomes between ADAPT and SRT combined with balloon-guide catheters (BGC).
Methods:
Patients undergoing thrombectomy for acute ischemic stroke at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Data was collected retrospectively from patient charts, procedure notes, and patient follow-up in neurology clinics. Clinical endpoint was the modified Rankin score (mRS) at 90-days, and technical outcomes were procedure time, total attempts, and mTICI scores.
Results:
The study included 2,016 patients (mean age 69±15) who underwent stroke thrombectomy using ADAPT (46%), SRT (46%), or SRT+BGC (8%). Similar baseline characteristics were observed between the three groups, and no significant difference in mRS scores at 90-days between the three groups in univariate and multivariate analyses. Thrombectomy performed using SRT+BGC required significantly shorter procedure time compared to SRT (35 vs 61 min, p<0.001) that was comparable to ADAPT (36 min, p>0.1). However, use of SRT+BGC required significantly lower number of aspiration attempts compared to ADAPT (median 1 vs. 2, p<0.05). On multivariate linear regression, use of SRT+BGC independent predicted a significant reduction in procedure time compared to SRT (coefficient=-30.6, p<0.001), and significantly lower number of attempts compared to ADAPT (coefficient=-0.4, p=0.01). SRT+BGC was an independent predictor of higher mortality compared to ADAPT (OR=2.4, p<0.01), despite comparable rates of favorable outcomes (mRS 0-2) between the two groups. Use of SRT+BGC was not an independent predictor of symptomatic hemorrhage or complications compared to SRT or ADAPT.
Conclusions:
This study shows that although ADAPT allows for faster procedure time compared to SRT, the use of BGC in SRT allows for a comparable procedure time to ADAPT with similar overall rates of favorable outcome, complications and hemorrhage. Mortality was higher with the use of BGC compared to ADAPT.
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Affiliation(s)
| | | | | | - Maya Eid
- Med Univ of South Carolina, Charleston, SC
| | | | - Adam Arthur
- The Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Joon-Tae Kim
- Chonnam National Univ Hosp, Kwangju, Korea, Democratic People’s Republic of
| | | | | | - Ilko Maier
- Universitätsmedizin Göttingen, Göttingen, Germany
| | | | | | | | - Kyle Fargen
- Wake Forest Baptist Health, Winston-Salem, NC
| | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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48
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McCarthy DJ, Saini V, Chen S, Luther E, Sheinberg D, Arthur A, Kim JT, De Leacy R, Maier I, Psychogios M, Rai A, Keyrouz S, Fargen K, Dumont T, Kan P, Alawieh A, Eyad A, Spiotta A, Starke R. Abstract TP15: A Multicenter Study Comparing Solumbra to Standard Aspiration and Stent Retriever Thrombectomy. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tp15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Standard mechanical thrombectomy (MT) techniques utilized include aspiration thrombectomy (ADAPT), stent retriever (SR), and a combination of both (Solumbra). Many studies compare outcomes between ADAPT and SR; however, there has yet to be a large multicenter investigation comparing ADAPT and SR to Solumbra.
Methods:
All patients from the participating STAR collaboration who underwent MT from 2015-2019 were included. Patients were analyzed by first MT technique utilized (ADAPT, SR, or Solumbra). Univariable and multivariable linear regression was utilized to analyze the MT technique association to number of thrombectomy attempts and procedure time. Univariable and multivariable logistic regression was utilized to determine the association between MT technique and the following outcomes: recanalization, symptomatic hemorrhage, 90-day functional independence, or 90-day mortality. P value less than 0.5 was considered significant.
Results:
A total of 2515 MT for stroke were identified: 1155 (46%) ADAPT, 735 (29%) SR, 625 (25%) Solumbra. Patients who received Solumbra MT were older (p<0.001), had higher IV-tPA administration rates (p<0.01), and lower onset-groin times (p<0.01). Separate multivariable linear regression analyses revealed that Solumbra technique had significantly high procedure times (OR 10.2, p<0.001) but less thrombectomy attempts (OR -0.8, p<0.001) compared to other MT techniques. There was no difference in recanalization success between techniques (ADAPT 85%, SR 84%, Solumbra 86%). Compared to Solumbra, ADAPT and SR thrombectomy had significantly lower incidence of symptomatic hemorrhage (ADAPT OR 0.32, p=0.009; SR OR 0.39, p=0.039) and ADAPT had a significantly lower likelihood of mortality (OR 0.50, p<0.001). There was no difference in 90-day functional independence (mRS≤2) rates between MT techniques.
Conclusion:
Compared to standard ADAPT and SR thrombectomy, the Solumbra technique for MT is a longer procedure that results in an increased likelihood of hemorrhage and 90-day mortality.
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Affiliation(s)
| | - Vasu Saini
- Neurology, Miami Miller Sch of Medicine, Miami, FL
| | | | - Evan Luther
- Neurosurgery, Miami Miller Sch of Medicine, Miami, FL
| | | | - Adam Arthur
- Baptist Memorial Hosp-Memphis, Tennessee, TN
| | - Joon-Tae Kim
- Chonnam National Univ Hosp,, Gwangju, Korea, Republic of
| | | | - Ilko Maier
- Univ Med Cntr Goettingen, Goettingen, Germany
| | | | | | | | | | | | | | | | | | | | - Robert Starke
- Neurosurgery, Miami Miller Sch of Medicine, Miami, FL
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49
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Saini V, Chalhoub RM, McCarthy DJ, Alawieh AM, Chen SH, Luther EM, Kan P, Keyrouz S, De Leacy R, Arthur A, Kim JT, Psychogios M, Rai A, Fargen K, Dumont T, Maier I, Peterson EC, Yavagal DR, Spiotta A, Starke RM. Abstract TP24: Radiological and Symptomatic Hemorrhagic Transformation Post Endovascular Thrombectomy for Both Anterior and Posterior Large Vessel Occlusion Ischemic Stroke - Insights From STAR Collaboration. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tp24] [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:
Radiological hemorrhagic transformation (rHT) and symptomatic intracranial hemorrhage (sICH) remain a major complication of mechanical thrombectomy (MT) in acute stroke. Our aim is to identify independent predictors of rHT and sICH.
Methods:
A retrospective multicenter international study across the US and Europe included 2499 patients, 18 years or older, who underwent EVT for acute stroke from 2015-2019. rHT is defined as any intracranial hemorrhage post MT and subgrouped per ECASS II as petechial (HI), parenchymal hematoma without (PH1) and with mass effect (PH2) and subarachnoid hemorrhage (SAH). sICH was defined as presence of PH2 or SAH. Functional outcomes were described using the 90-day modified Rankin score (mRS) as “good” 0-2 or “poor” 3-6. Multivariable logistic regression model was used to identify predictors of rHT and sICH.
Results:
600 (24%) had rHT and 145 (5.8%) had sICH. On multivariable regression model, independent predictors for both rHT and sICH were higher admission NIHSS (OR 1.03, p<.001 vs. OR 1.04, p<.001), lower ASPECTS (OR .82, p<.001 vs. OR .83, p<.001) and higher number of thrombectomy attempts (OR 1.08, p.013 vs. OR 1.08, p .014). Patients with hyperlipidemia (OR .77, p .03 vs. OR .75, p.02) or posterior circulation strokes (OR .59, p .013 vs. OR .58, p .01) had significantly lower rates of rHT and sICH. Both rHT and sICH are independently associated with poor functional outcomes (OR .5, p<.001; OR .29, p .006).
Conclusion:
Compared to posterior circulation, anterior circulation strokes have higher rates of rHT and sICH. Baseline hyperlipidemia is protective for rHT or sICH post MT and this association needs further study. Clinical severity of stroke, poor ASPECTS on admission and higher thrombectomy attempts are associated with higher rates of rHT or sICH. Both rHT and sICH are independently associated with poor functional outcomes.
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Affiliation(s)
- Vasu Saini
- Univ of Miami, Miller Sch of Medicine, Miami, FL
| | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
| | | | | | - Adam Arthur
- The Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Joon-Tae Kim
- Chonnam National Univ Hosp, South Korea, Kwangju, Korea, Republic of
| | | | | | - Kyle Fargen
- Wake Forest Baptist Health, Winston-Salem, NC
| | | | - Ilko Maier
- Universitätsmedizin Göttingen, Göttingen, Germany
| | | | | | | | - Robert M Starke
- Neurosurgery, Univ of Miami, Miller Sch of Medicine, Miami, FL
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50
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Psychogios M, Maier I, Tsogkas I, Hesse A, Brehm A, Behme D, Schnieder M, Schregel K, Papageorgiou I, Liebeskind D, Goyal M, Liman J. Abstract TMP3: One-stop Management of 230 Consecutive Acute Stroke Patients Report of Procedural Times and Clinical Outcome. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tmp3] [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
Introdruction:
Rapid thrombectomy for acute ischemic stroke caused by large vessel occlusion leads to improved outcome. Optimizing intrahospital management might diminish treatment delays. To examine if one-stop management reduces intrahospital treatment delays and improves functional outcome of acute stroke patients with large vessel occlusion.
Methods:
We performed a single center, observational study from June 2016 to November 2018. Imaging was acquired with the latest generation angiography suite at a comprehensive stroke center. Two-hundred-thirty consecutive adults with suspected acute stroke presenting within 6 hours after symptom onset with a moderate to severe National Institutes of Health Stroke Scale (≥ 10 in 2016; ≥ 7 since January 2017) were directly transported to the angiography suite by bypassing multidetector CT. Noncontrast flat-detector CT and biphasic flat-detector CT angiography were acquired with an angiography system. In case of a large vessel occlusion patients remained in the angiography suite, received intravenous rtPA therapy and underwent thrombectomy. As primary endpoints, door-to-reperfusion times and functional outcome at 90 days were recorded and compared in a case-control analysis with matched prior patients receiving standard management.
Results:
A total of 230 patients (123 women, median age of 78 years (IQR 69-84)) were included. Median symptom-to-door time was 130 min (IQR 70-195). Large vessel occlusion was diagnosed in 166/230 (72%) patients; 64/230 (28%) had conditions not suitable for thrombectomy. Median door-to-reperfusion time for M1 occlusions was 64 min (IQR 56-87). Compared to 43 case-matched patients triaged with multidetector CT, median door-to-reperfusion time was reduced from 102 (IQR 85-117) to 68 min (IQR 53-89;
P
<0.001). Rate of good functional outcome was significantly better in the one-stop management group (
P
=0.029). Safety parameters (mortality, sICH, any hemorrhage) did not differ significantly between groups.
Conclusions:
One-stop management for stroke triage reduces intrahospital time delays in our specific hospital setting.
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Affiliation(s)
| | - Ilko Maier
- Univ Hosp Goettingen, Goettingen, Germany
| | | | | | | | | | | | | | | | | | | | - Jan Liman
- Univ Hosp Goettingen, Goettingen, Germany
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