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Colangelo G, Ribo M, Montiel E, Dominguez D, Olivé-Gadea M, Muchada M, Garcia-Tornel Á, Requena M, Pagola J, Juega J, Rodriguez-Luna D, Rodriguez-Villatoro N, Rizzo F, Taborda B, Molina CA, Rubiera M. PRERISK: A Personalized, Artificial Intelligence-Based and Statistically-Based Stroke Recurrence Predictor for Recurrent Stroke. Stroke 2024; 55:1200-1209. [PMID: 38545798 DOI: 10.1161/strokeaha.123.043691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 01/31/2024] [Indexed: 04/24/2024]
Abstract
BACKGROUND Predicting stroke recurrence for individual patients is difficult, but individualized prediction may improve stroke survivors' engagement in self-care. We developed PRERISK: a statistical and machine learning classifier to predict individual risk of stroke recurrence. METHODS We analyzed clinical and socioeconomic data from a prospectively collected public health care-based data set of 41 975 patients admitted with stroke diagnosis in 88 public health centers over 6 years (2014-2020) in Catalonia-Spain. A new stroke diagnosis at least 24 hours after the index event was considered as a recurrent stroke, which was considered as our outcome of interest. We trained several supervised machine learning models to provide individualized risk over time and compared them with a Cox regression model. Models were trained to predict early, late, and long-term recurrence risk, within 90, 91 to 365, and >365 days, respectively. C statistics and area under the receiver operating characteristic curve were used to assess the accuracy of the models. RESULTS Overall, 16.21% (5932 of 36 114) of patients had stroke recurrence during a median follow-up of 2.69 years. The most powerful predictors of stroke recurrence were time from previous stroke, Barthel Index, atrial fibrillation, dyslipidemia, age, diabetes, and sex, which were used to create a simplified model with similar performance, together with modifiable vascular risk factors (glycemia, body mass index, high blood pressure, cholesterol, tobacco dependence, and alcohol abuse). The areas under the receiver operating characteristic curve were 0.76 (95% CI, 0.74-0.77), 0.60 (95% CI, 0.58-0.61), and 0.71 (95% CI, 0.69-0.72) for early, late, and long-term recurrence risk, respectively. The areas under the receiver operating characteristic curve of the Cox risk class probability were 0.73 (95% CI, 0.72-0.75), 0.59 (95% CI, 0.57-0.61), and 0.67 (95% CI, 0.66-0.70); machine learning approaches (random forest and AdaBoost) showed statistically significant improvement (P<0.05) over the Cox model for the 3 recurrence time periods. Stroke recurrence curves can be simulated for each patient under different degrees of control of modifiable factors. CONCLUSIONS PRERISK is a novel approach that provides a personalized and fairly accurate risk prediction of stroke recurrence over time. The model has the potential to incorporate dynamic control of risk factors.
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Affiliation(s)
- Giorgio Colangelo
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Nora Health, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., E.M.)
| | - Marc Ribo
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Estefanía Montiel
- Nora Health, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., E.M.)
| | - Didier Dominguez
- Programa d'Analítica de Dades per a la Recerca i la Innovació en Salut, Agència de Qualitat i Avaluació Sanitàries de Catalunya, Departament de Salut, Generalitat de Catalunya, Carrer de Roc Boronat, Barcelona, Spain (D.D.)
| | - Marta Olivé-Gadea
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Marian Muchada
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Álvaro Garcia-Tornel
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Manuel Requena
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Jorge Pagola
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Jesús Juega
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - David Rodriguez-Luna
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Noelia Rodriguez-Villatoro
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Federica Rizzo
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Belén Taborda
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Carlos A Molina
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Marta Rubiera
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
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Pancorbo O, Sanjuan E, Rodríguez-Samaniego MT, Miñarro O, Simonetti R, Olivé-Gadea M, García-Tornel Á, Rodriguez-Villatoro N, Muchada M, Rubiera M, Álvarez-Sabin J, Molina CA, Rodriguez-Luna D. Enhancing blood pressure management protocol implementation in patients with acute intracerebral haemorrhage through a nursing-led approach: A retrospective cohort study. J Clin Nurs 2024; 33:1398-1408. [PMID: 38379362 DOI: 10.1111/jocn.17080] [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: 11/30/2023] [Revised: 01/03/2024] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
AIM To evaluate the impact of nurse care changes in implementing a blood pressure management protocol on achieving rapid, intensive and sustained blood pressure reduction in acute intracerebral haemorrhage patients. DESIGN Retrospective cohort study of prospectively collected data over 6 years. METHODS Intracerebral haemorrhage patients within 6 h and systolic blood pressure ≥ 150 mmHg followed a rapid (starting treatment at computed tomography suite with a target achievement goal of ≤60 min), intensive (target systolic blood pressure < 140 mmHg) and sustained (maintaining target stability for 24 h) blood pressure management plan. We differentiated six periods: P1, stroke nurse at computed tomography suite (baseline period); P2, antihypertensive titration by stroke nurse; P3, retraining by neurologists; P4, integration of a stroke advanced practice nurse; P5, after COVID-19 impact; and P6, retraining by stroke advanced practice nurse. Outcomes included first-hour target achievement (primary outcome), tomography-to-treatment and treatment-to-target times, first-hour maximum dose of antihypertensive treatment and 6-h and 24-h systolic blood pressure variability. RESULTS Compared to P1, antihypertensive titration by stroke nurses (P2) reduced treatment-to-target time and increased the rate of first-hour target achievement, retraining of stroke nurses by neurologists (P3) maintained a higher rate of first-hour target achievement and the integration of a stroke advanced practice nurse (P4) reduced both 6-h and 24-h systolic blood pressure variability. However, 6-h systolic blood pressure variability increased from P4 to P5 following the impact of the COVID-19 pandemic. Finally, compared to P1, retraining of stroke nurses by stroke advanced practice nurse (P6) reduced tomography-to-treatment time and increased the first-hour maximum dose of antihypertensive treatment. CONCLUSION Changes in nursing care and continuous education can significantly enhance the time metrics and blood pressure outcomes in acute intracerebral haemorrhage patients. REPORTING METHOD STROBE guidelines. PATIENT AND PUBLIC CONTRIBUTION No Patient or Public Contribution.
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Affiliation(s)
- Olalla Pancorbo
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Estela Sanjuan
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | | | - Olga Miñarro
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Renato Simonetti
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marta Olivé-Gadea
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Álvaro García-Tornel
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marián Muchada
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marta Rubiera
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - José Álvarez-Sabin
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Carlos A Molina
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Rodriguez-Luna
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
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Hernandez D, Requena M, Olivé-Gadea M, de Dios M, Gramegna LL, Muchada M, García-Tornel Á, Diana F, Rizzo F, Rivera E, Rubiera M, Piñana C, Rodrigo-Gisbert M, Rodríguez-Luna D, Pagola J, Carmona T, Juega J, Rodríguez-Villatoro N, Molina C, Ribo M, Tomasello A. Radial Versus Femoral Access for Mechanical Thrombectomy in Patients With Stroke: A Noninferiority Randomized Clinical Trial. Stroke 2024; 55:840-848. [PMID: 38527149 DOI: 10.1161/strokeaha.124.046360] [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: 01/02/2024] [Accepted: 01/25/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Transfemoral access is predominantly used for mechanical thrombectomy in patients with stroke with a large vessel occlusion. Following the interventional cardiology guidelines, routine transradial access has been proposed as an alternative, although its safety and efficacy remain controversial. We aim to explore the noninferiority of radial access in terms of final recanalization. METHODS The study was an investigator-initiated, single-center, evaluator-blinded, noninferiority randomized clinical trial. Patients with stroke undergoing mechanical thrombectomy, with a patent femoral artery and a radial artery diameter ≥2.5 mm, were randomly assigned (1:1) to either transradial (60 patients) or transfemoral access (60 patients). The primary binary outcome was the successful recanalization (expanded Treatment in Cerebral Ischemia score, 2b-3) assigned by blinded evaluators. We established a noninferiority margin of -13.2%, considering an acceptable reduction of 15% in the expected recanalization rates. RESULTS From September 2021 to July 2023, 120 patients were randomly assigned and 116 (58 transradial access and 58 transfemoral access) with confirmed intracranial occlusion on the initial angiogram were included in the intention-to-treat analysis. Successful recanalization was achieved in 51 (87.9%) patients assigned to transfemoral access and in 56/58 (96.6%) patients assigned to transradial (adjusted 1 side risk difference [RD], -5.0% [95% CI, -6.61% to +13.1%]) showing noninferiority of transradial access. Median time from angiosuite arrival to first pass (femoral, 30 [interquartile range, 25-37] minutes versus radial: 41 [interquartile range, 33-62] minutes; P<0.001) and from angiosuite arrival to recanalization (femoral: 42 (IQR, 28-74) versus radial: 59.5 (IQR, 44-81) minutes; P<0.050) were longer in the transradial access group. Both groups presented 1 severe access complication and there was no difference in the rate of access conversion: transradial 7 (12.1%) versus transfemoral 5 (8.6%) (P=0.751). CONCLUSIONS Among patients who underwent mechanical thrombectomy, transradial access was noninferior to transfemoral access in terms of final recanalization. Procedural delays may favor transfemoral access as the default first-line approach. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05225636.
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Affiliation(s)
- David Hernandez
- Neuroradiologia Intervencionista (D.H., M. Requena, M.d.D., F.D., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Manuel Requena
- Neuroradiologia Intervencionista (D.H., M. Requena, M.d.D., F.D., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Marta Olivé-Gadea
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Marta de Dios
- Neuroradiologia Intervencionista (D.H., M. Requena, M.d.D., F.D., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Laura Ludovica Gramegna
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Marian Muchada
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Álvaro García-Tornel
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Francesco Diana
- Neuroradiologia Intervencionista (D.H., M. Requena, M.d.D., F.D., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Federica Rizzo
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Eila Rivera
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Marta Rubiera
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Carlos Piñana
- Interventional Radiology Unit, Hospital Clínico Universitario de Valencia, Spain (C.P.)
| | - Marc Rodrigo-Gisbert
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - David Rodríguez-Luna
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Jorge Pagola
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Tomás Carmona
- Neurosurgery Department, Hospital San Pablo, Coquimbo, Chile (T.C.)
| | - Jesús Juega
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Noelia Rodríguez-Villatoro
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Carlos Molina
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Marc Ribo
- Unitat d'Ictus (M. Requena, M.O.-G., M.M., A.G.-T., F.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
| | - Alejandro Tomasello
- Neuroradiologia Intervencionista (D.H., M. Requena, M.d.D., F.D., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain (D.H., M. Requena, M.O.-G., M.d.D., L.L.G., M.M., A.G.-T., F.D., F.R., E.R., M. Rubiera, M.R.-G., D.R.-L., J.P., J.J., N.R.-V., C.M., M.R., A.T.)
- Departament de Medicina, Universitat Autonoma de Barcelona, Spain (A.T.)
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4
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Rodríguez I, Gramegna LL, Requena M, Rizzuti M, Elosua I, Mayol J, Olivé-Gadea M, Diana F, Rodrigo-Gisbert M, Muchada M, Rivera E, García-Tornel Á, Rizzo F, De Dios M, Rodríguez-Luna D, Piñana C, Pagola J, Hernández D, Juega J, Rodríguez N, Quintana M, Molina C, Ribo M, Tomasello A. Safety and efficacy of early carotid artery stenting in patients with symptomatic stenosis. Interv Neuroradiol 2024:15910199241239204. [PMID: 38515363 DOI: 10.1177/15910199241239204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Symptomatic carotid artery stenosis is a significant contributor to ischemic strokes. Carotid artery stenting (CAS) is usually indicated for secondary stroke prevention. This study evaluates the safety and efficacy of CAS performed within a short time frame from symptom onset. METHODS We conducted a single-center, retrospective study of consecutive patients who underwent CAS for symptomatic carotid stenosis within eight days of symptom onset from July 2019 to January 2022. Data on demographics, medical history, procedural details, and follow-up outcomes were analyzed. The primary outcome measure was the recurrence of the stroke within the first month post-procedure. Secondary outcomes included mortality, the rate of intra-procedural complications, and hyperperfusion syndrome. RESULTS We included 93 patients with a mean age of 71.7 ± 11.7 years. The median time from symptom onset to CAS was 96 h. The rate of stroke recurrence was 5.4% in the first month, with a significant association between the number of stents used and increased recurrence risk. Mortality within the first month was 3.2%, with an overall mortality rate of 11.8% after a median follow-up of 19 months. Intra-procedural complications were present in five (5.4%) cases and were related to the number of stents used (p = 0.002) and post-procedural angioplasty (p = 0.045). Hyperperfusion syndrome occurred in 3.2% of cases. CONCLUSION Early CAS within the high-risk window post-symptom onset is a viable secondary stroke prevention strategy in patients with symptomatic carotid artery stenosis. The procedure rate of complication is acceptable, with a low recurrence of stroke. However, further careful selection of patients for this procedural strategy is crucial to optimize outcomes.
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Affiliation(s)
- Isabel Rodríguez
- Interventional Neuroradiology Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Laura Ludovica Gramegna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Manuel Requena
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | | | - Iker Elosua
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Jordi Mayol
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marta Olivé-Gadea
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Francesco Diana
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Rodrigo-Gisbert
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marián Muchada
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Eila Rivera
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Álvaro García-Tornel
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Federica Rizzo
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marta De Dios
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - David Rodríguez-Luna
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Carlos Piñana
- Interventional Radiology, Hospital Clínico Valencia, Barcelona, Spain
| | - Jorge Pagola
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - David Hernández
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jesús Juega
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Noelia Rodríguez
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Marc Ribo
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron Barcelona Spain, Barcelona, Spain
| | - Alejandro Tomasello
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Department of Radiology, Interventional Neuroradiology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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5
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Rabaneda-Lombarte N, Faura J, Ezcurra-Díaz G, Olivé-Gadea M, Álvarez-Larruy M, Vidal-de Francisco D, Domínguez-Mayoral A, Avellaneda C, Freijo MM, Zapata-Arriaza E, Serrano-Heras G, Alcahut-Rodríguez C, Fernández-Pérez I, Moniche F, Pérez-Sánchez S, Millán M, Rubiera M, Dorado L, Maisterra O, Montaner J, Bustamante A. Stroke-associated pneumonia according to mCDC criteria: impact on prognosis and antibiotic therapy. Front Neurol 2024; 15:1358628. [PMID: 38497035 PMCID: PMC10941756 DOI: 10.3389/fneur.2024.1358628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/13/2024] [Indexed: 03/19/2024] Open
Abstract
Objective The modified Centers for Disease Control and Prevention (mCDC) criteria have been proposed for diagnosing and managing stroke-associated pneumonia (SAP). The objective was to investigate the impact of SAP on stroke outcome depending on whether or not it conforms to mCDC criteria. Our secondary objective was to identify the responsible factors for antibiotic initiation in stroke patients. Methods We conducted a prospective, multicenter, observational study of ischemic stroke patients with moderate to severe stroke (NIHSS≥4) admitted within 24 h. For 7 days, mCDC criteria were assessed daily, and infections and antibiotics were recorded. Pneumonias were divided into those fulfilling mCDC criteria (mCDC-SAP) or not (other pneumonias, OPn). The effect of each type of pneumonia on 3-month outcome was evaluated in separated logistic regression models. Factors associated with antibiotic initiation were explored using a random forest analysis. Results Of the 342 patients studied, infections were diagnosed in 72 (21.6%), including 39 (11.7%) cases of pneumonia. Of them, 25 (7.5%) fulfilled mCDC criteria. Antibiotics were used in 92% of mCDC-SAP and 64.3% of OPn. In logistic regression analysis, mCDC-SAP, but not OPn, was an independent predictor of poor outcome [OR, 4.939 (1.022-23.868)]. The random forest analysis revealed that fever had the highest importance for antibiotic initiation. Interpretation The mCDC criteria might be useful for detecting clinically relevant SAP, which is associated with poor outcomes. Isolated signs of infection were more important for antibiotic initiation than compliance with pre-defined criteria. Therefore, adherence to mCDC criteria might result in antibiotic saving without compromising clinical outcome.
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Affiliation(s)
- Neus Rabaneda-Lombarte
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Júlia Faura
- Vall d'Hebrón Institute of Research, Barcelona, Spain
| | - Garbiñe Ezcurra-Díaz
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Marta Álvarez-Larruy
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | | | | | | | | | | | | | | | | | - Mònica Millán
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Marta Rubiera
- Hospital Universitari Vall d’Hebrón, Barcelona, Spain
| | - Laura Dorado
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Joan Montaner
- Vall d'Hebrón Institute of Research, Barcelona, Spain
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Alejandro Bustamante
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
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6
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Rodrigo-Gisbert M, García-Tornel A, Requena M, Vielba-Gómez I, Bashir S, Rubiera M, De Dios Lascuevas M, Olivé-Gadea M, Piñana C, Rizzo F, Muchada M, Rodriguez-Villatoro N, Rodríguez-Luna D, Juega J, Pagola J, Hernández D, Molina CA, Terceño M, Tomasello A, Ribo M. Clinico-radiological features of intracranial atherosclerosis-related large vessel occlusion prior to endovascular treatment. Sci Rep 2024; 14:2945. [PMID: 38316891 PMCID: PMC10844212 DOI: 10.1038/s41598-024-53354-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 09/15/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024] Open
Abstract
The identification of large vessel occlusion with underlying intracranial atherosclerotic disease (ICAS-LVO) before endovascular treatment (EVT) continues to be a challenge. We aimed to analyze baseline clinical-radiological features associated with ICAS-LVO that could lead to a prompt identification. We performed a retrospective cross-sectional study of consecutive patients with stroke treated with EVT from January 2020 to April 2022. We included anterior LVO involving intracranial internal carotid artery and middle cerebral artery. We analyzed baseline clinical and radiological variables associated with ICAS-LVO and evaluated the diagnostic value of a multivariate logistic regression model to identify ICAS-LVO before EVT. ICAS-LVO was defined as presence of angiographic residual stenosis or a trend to re-occlusion during EVT procedure. A total of 338 patients were included in the study. Of them, 28 patients (8.3%) presented with ICAS-LVO. After adjusting for confounders, absence of atrial fibrillation (OR 9.33, 95% CI 1.11-78.42; p = 0.040), lower hypoperfusion intensity ratio (HIR [Tmax > 10 s/Tmax > 6 s ratio], (OR 0.69, 95% CI 0.50-0.95; p = 0.025), symptomatic intracranial artery calcification (IAC, OR .15, 95% CI 1.64-26.42, p = 0.006), a more proximal occlusion (ICA, MCA-M1: OR 4.00, 95% CI 1.23-13.03; p = 0.021), and smoking (OR 2.91, 95% CI 1.08-7.90; p = 0.035) were associated with ICAS-LVO. The clinico-radiological model showed an overall well capability to identify ICAS-LVO (AUC = 0.88, 95% CI 0.83-0.94; p < 0.001). In conclusion, a combination of clinical and radiological features available before EVT can help to identify an ICAS-LVO. This approach could be useful to perform a rapid assessment of underlying etiology and suggest specific pathophysiology-based measures. Prospective studies are needed to validate these findings in other populations.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Isabel Vielba-Gómez
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Saima Bashir
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Piñana
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Rodríguez-Luna
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesus Juega
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Hernández
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mikel Terceño
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Alejandro Tomasello
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
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7
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Rodriguez-Luna D, Pancorbo O, Coscojuela P, Lozano P, Rizzo F, Olivé-Gadea M, Requena M, García-Tornel Á, Rodríguez-Villatoro N, Juega JM, Boned S, Muchada M, Pagola J, Rubiera M, Ribo M, Tomasello A, Molina CA. Derivation and validation of three intracerebral hemorrhage expansion scores using different CT modalities. Eur Radiol 2023; 33:6045-6053. [PMID: 37059906 DOI: 10.1007/s00330-023-09621-0] [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: 11/09/2022] [Revised: 01/26/2023] [Accepted: 02/13/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVES To derivate and validate three scores for the prediction of intracerebral hemorrhage (ICH) expansion depending on the use of non-contrast CT (NCCT), single-phase CTA, or multiphase CTA markers of hematoma expansion, and to evaluate the added value of single-phase and multiphase CTA over NCCT. METHODS After prospectively deriving NCCT, single-phase CTA, and multiphase CTA hematoma expansion scores in 156 patients with ICH < 6 h, we validated them in 120 different patients. Discrimination and calibration of the three scores was assessed. Primary outcome was substantial hematoma expansion > 6 mL or > 33% at 24 h. RESULTS The evaluation of single-phase and multiphase CTA markers gave a steadily increase in discrimination for substantial hematoma expansion over NCCT markers. The C-index (95% confidence interval) in derivation and validation cohorts was 0.69 (0.58-0.80) and 0.59 (0.46-0.72) for NCCT score, significantly lower than 0.75 ([0.64-0.87], p = 0.038) and 0.72 ([0.59-0.84], p = 0.016) for single-phase CTA score, and than 0.79 ([0.68-0.89], p = 0.033) and 0.73 ([0.62-0.85], p = 0.031) for multiphase CTA score, respectively. The three scores showed good calibration in both derivation and validation cohorts: NCCT (χ2 statistic 0.389, p = 0.533; and χ2 statistic 0.352, p = 0.553), single-phase CTA (χ2 statistic 2.052, p = 0.359; and χ2 statistic 2.230, p = 0.328), and multiphase CTA (χ2 statistic 0.559, p = 0.455; and χ2 statistic 0.020, p = 0.887) scores, respectively. CONCLUSION This study shows the added prognostic value of more advanced CT modalities in acute ICH evaluation. NCCT, single-phase CTA, and multiphase CTA scores may help to refine the selection of patients at risk of expansion in different decision-making scenarios. KEY POINTS • This study shows the added prognostic value of more advanced CT modalities in acute intracerebral hemorrhage evaluation. • The evaluation of single-phase and multiphase CTA markers provides a steadily increase in discrimination for intracerebral hemorrhage expansion over non-contrast CT markers. • Non-contrast CT, single-phase CTA, and multiphase CTA scores may help clinicians and researchers to refine the selection of patients at risk of intracerebral hemorrhage expansion in different decision-making scenarios.
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Affiliation(s)
- David Rodriguez-Luna
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain.
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.
- Blanquerna School of Health Sciences, Ramon Llull University, Barcelona, Spain.
| | - Olalla Pancorbo
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
- Blanquerna School of Health Sciences, Ramon Llull University, Barcelona, Spain
| | - Pilar Coscojuela
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Prudencio Lozano
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Federica Rizzo
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Álvaro García-Tornel
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Jesús M Juega
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Sandra Boned
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marián Muchada
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Jorge Pagola
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marta Rubiera
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Alejandro Tomasello
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Carlos A Molina
- Department of Neurology, Vall d'Hebron University Hospital, Ps Vall d'Hebron 119, 08035, Barcelona, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
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8
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Galecio-Castillo M, Farooqui M, Hassan AE, Jumaa MA, Divani AA, Ribo M, Abraham M, Petersen NH, Fifi JT, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Sheth S, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Tekle W, Zaidi SF, Sabbagh SY, Olivé-Gadea M, Barkley T, Leacy RD, Sprankle KW, Abdalkader M, Salazar-Marioni S, Soomro J, Gordon W, Turabova C, Vivanco-Suarez J, Rodriguez-Calienes A, Mokin M, Yavagal DR, Jovin T, Ortega-Gutierrez S. Clinical and Safety Outcomes of Endovascular Therapy 6 to 24 Hours After Large Vessel Occlusion Ischemic Stroke With Tandem Lesions. J Stroke 2023; 25:378-387. [PMID: 37607694 PMCID: PMC10574302 DOI: 10.5853/jos.2023.00759] [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: 03/09/2023] [Revised: 05/09/2023] [Accepted: 05/25/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6-24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6-24 hours. METHODS This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (<6 hours), and late window (6-24 hours). Primary clinical and safety outcomes were 90-day functional independence measured by the modified Rankin Scale (mRS: 0-2) and symptomatic intracranial hemorrhage (sICH). Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), first-pass effect, early neurological improvement, ordinal mRS, and in-hospital and 90-day mortality. RESULTS Of 579 patients (median age 68, 32.1% females), 268 (46.3%) were treated in the late window and 311 (53.7%) in the early window. Late window group had lower median National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early Computed Tomography Score, rates of intravenous thrombolysis, and higher rates for perfusion imaging. After adjusting for confounders, the odds of 90-day mRS 0-2 (47.7% vs. 45.0%, adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.49-1.02), favorable shift in mRS (aOR 0.88, 95% CI 0.44-1.76), and sICH (3.7% vs. 5.2%, aOR 0.56, 95% CI 0.20-1.56) were similar in both groups. There was no difference in secondary outcomes. Increased time from LKW to puncture did not predicted the probability of 90-day mRS 0-2 (aOR 0.99, 95% CI 0.96-1.01, for each hour delay) among patients presenting <24 hours. CONCLUSION EVT for acute TL-LVO treated within 6-24 hours after LKW was associated with similar rates of clinical and safety outcomes, compared to patients treated within 6 hours.
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Affiliation(s)
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | | | - Afshin A. Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Marc Ribo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Nils H. Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Johanna T. Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Waldo R. Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Amer M. Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Thanh N. Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Sunil Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA
| | | | | | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Wondwossen Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Syed F. Zaidi
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Sara Y. Sabbagh
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | | | - Tiffany Barkley
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jazba Soomro
- Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | - Weston Gordon
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - Charoskhon Turabova
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Maxim Mokin
- Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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9
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Juega J, Li J, Palacio-Garcia C, Rodriguez M, Tiberi R, Piñana C, Rodriguez-Luna D, Requena M, García-Tornel Á, Rodriguez-Villatoro N, Rubiera M, Muchada M, Olivé-Gadea M, Rizzo F, Hernandez D, Dios-Lascuevas M, Hernandez-Perez M, Dorado L, Quesada H, Cardona P, De La Torre C, Gallur L, Camacho J, Ramon-Y-Cajal S, Tomasello A, Ribó M, Molina CA, Pagola J. Granulocytes-Rich Thrombi in Cerebral Large Vessel Occlusion Are Associated with Increased Stiffness and Poorer Revascularization Outcomes. Neurotherapeutics 2023; 20:1167-1176. [PMID: 37212981 PMCID: PMC10457261 DOI: 10.1007/s13311-023-01385-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/23/2023] Open
Abstract
We aim to identify a profile of intracranial thrombus resistant to recanalization by mechanical thrombectomy (MT) in acute stroke treatment. The first extracted clot of each MT was analyzed by flow cytometry obtaining the composition of the main leukocyte populations: granulocytes, monocytes, and lymphocytes. Demographics, reperfusion treatment, and grade of recanalization were registered. MT failure (MTF) was defined as final thrombolysis in cerebral infarction score IIa or lower and/or need of permanent intracranial stenting as a rescue therapy. To explore the relationship between stiffness of intracranial clots and cellular composition, unconfined compression tests were performed in other cohorts of cases. Thrombi obtained in 225 patients were analyzed. MTF were observed in 30 cases (13%). MTF was associated with atherosclerosis etiology (33.3% vs. 15.9%; p = 0.021) and higher number of passes (3 vs. 2; p < 0.001). Clot analysis of MTF showed higher percentage of granulocytes [82.46 vs. 68.90% p < 0.001] and lower percentage of monocytes [9.18% vs.17.34%, p < 0.001] in comparison to successful MT cases. The proportion of clot granulocytes (aOR 1.07; 95% CI 1.01-1.14) remained an independent marker of MTF. Among thirty-eight clots mechanically tested, there was a positive correlation between granulocyte proportion and thrombi stiffness (Pearson's r = 0.35, p = 0.032), with a median clot stiffness of 30.2 (IQR, 18.9-42.7) kPa. Granulocytes-rich thrombi are harder to capture by mechanical thrombectomy due to increased stiffness, so a proportion of intracranial granulocytes might be useful to guide personalized endovascular procedures in acute stroke treatment.
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Affiliation(s)
- Jesús Juega
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Jiahui Li
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | | | - Maite Rodriguez
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Riccardo Tiberi
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Carlos Piñana
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - David Hernandez
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marta Dios-Lascuevas
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Laura Dorado
- Department of Neurology, Germans Trias I Pujol University Hospital, Badalona, Spain
| | - Helena Quesada
- Department of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Pere Cardona
- Department of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Carolina De La Torre
- Proteomics Unit, Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Laura Gallur
- Hematology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jessica Camacho
- Department of Pathology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Alejandro Tomasello
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain.
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
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10
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Canals P, Balocco S, Díaz O, Li J, García-Tornel A, Tomasello A, Olivé-Gadea M, Ribó M. A fully automatic method for vascular tortuosity feature extraction in the supra-aortic region: unraveling possibilities in stroke treatment planning. Comput Med Imaging Graph 2023; 104:102170. [PMID: 36634467 DOI: 10.1016/j.compmedimag.2022.102170] [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: 03/23/2022] [Revised: 11/14/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022]
Abstract
Vascular tortuosity of supra-aortic vessels is widely considered one of the main reasons for failure and delays in endovascular treatment of large vessel occlusion in patients with acute ischemic stroke. Characterization of tortuosity is a challenging task due to the lack of objective, robust and effective analysis tools. We present a fully automatic method for arterial segmentation, vessel labelling and tortuosity feature extraction applied to the supra-aortic region. A sample of 566 computed tomography angiography scans from acute ischemic stroke patients (aged 74.8 ± 12.9, 51.0% females) were used for training, validation and testing of a segmentation module based on a U-Net architecture (162 cases) and a vessel labelling module powered by a graph U-Net (566 cases). Successively, 30 cases were processed for testing of a tortuosity feature extraction module. Measurements obtained through automatic processing were compared to manual annotations from two observers for a thorough validation of the method. The proposed feature extraction method presented similar performance to the inter-rater variability observed in the measurement of 33 geometrical and morphological features of the arterial anatomy in the supra-aortic region. This system will contribute to the development of more complex models to advance the treatment of stroke by adding immediate automation, objectivity, repeatability and robustness to the vascular tortuosity characterization of patients.
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Affiliation(s)
- P Canals
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - S Balocco
- Department of Mathematics and Computer Science, University of Barcelona, Barcelona, Spain; Computer Vision Center, Bellaterra, Spain
| | - O Díaz
- Department of Mathematics and Computer Science, University of Barcelona, Barcelona, Spain
| | - J Li
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A García-Tornel
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Tomasello
- Neuroradiology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - M Olivé-Gadea
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Ribó
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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11
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Rodrigo-Gisbert M, Requena M, Rubiera M, Khalife J, Lozano P, De Dios Lascuevas M, García-Tornel Á, Olivé-Gadea M, Piñana C, Rizzo F, Boned S, Muchada M, Rodríguez-Villatoro N, Rodríguez-Luna D, Juega J, Pagola J, Hernández D, Molina CA, Tomasello A, Ribo M. Intracranial Artery Calcifications Profile as a Predictor of Recanalization Failure in Endovascular Stroke Treatment. Stroke 2023; 54:430-438. [PMID: 36689597 DOI: 10.1161/strokeaha.122.041257] [Citation(s) in RCA: 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: 09/08/2022] [Accepted: 12/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Acute ischemic stroke with large or medium-vessel occlusion associated with intracranial artery calcification (IAC) is an infrequent phenomenon presumably associated with intracranial atherosclerotic disease. We aimed to characterize IAC and its impact on endovascular treatment outcomes. METHODS We performed a retrospective cross-sectional study of consecutive patients with stroke treated with thrombectomy from January 2020 to July 2021 in our institution. We described IAC findings (length, density, and location pattern) on baseline noncontrast computed tomography. Patients were divided into 3 groups: IAC related to the occlusion location (symptomatic-IAC group), unrelated to the occlusion (asymptomatic-IAC group), and absence of any IAC (non-IAC group). We analyzed the association between the IAC profile and outcomes using logistic regression models. Intracranial angioplasty and stenting were considered rescue treatments. RESULTS Of the 393 patients included, 26 (6.6%) patients presented a symptomatic-IAC, 77 (19.6%) patients an asymptomatic-IAC, and in 290 (73.8%) patients no IAC was observed. The rate of failed recanalization (expanded Thrombolysis in Cerebral Infarction 0-2a) before rescue treatment was higher in symptomatic-IAC (65.4%) than in asymptomatic-IAC (15.6%; P<0.001) or non-IAC (13.4%; P<0.001). Rescue procedures were more frequently performed in symptomatic-IAC (26.9%) than in asymptomatic-IAC (1.3%; P<0.001) and non-IAC (4.1%; P<0.001). After adjusting for identifiable clinical and radiological confounders, symptomatic-IAC emerged as an independent predictor of failed recanalization (odds ratio, 11.89 [95% CI, 3.94-35.91]; P<0.001), adoption of rescue procedures (odds ratio, 12.38 [95% CI, 2.22-69.09]; P=0.004), and poor functional outcome (90-day modified Rankin Scale score ≥3; odds ratio, 3.51 [95% CI, 1.02-12.00]; P=0.046). CONCLUSIONS The presence of IAC related to the occlusion location is associated with worse angiographic and functional outcomes. Therefore, identification of symptomatic-IAC on baseline imaging may guide optimal endovascular treatment strategy, predicting the need for intracranial stenting and angioplasty.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ (J.K.)
| | - Prudencio Lozano
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta De Dios Lascuevas
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Carlos Piñana
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (C.P., D.H.)
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Sandra Boned
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - David Rodríguez-Luna
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jesús Juega
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - David Hernández
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (C.P., D.H.)
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Alejandro Tomasello
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
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Sarraj A, Kleinig TJ, Hassan AE, Portela PC, Ortega-Gutierrez S, Abraham MG, Manning NW, Siegler JE, Goyal N, Maali L, Blackburn S, Wu TY, Blasco J, Renú A, Sangha NS, Arenillas JF, McCullough-Hicks ME, Wallace A, Gibson D, Pujara DK, Shaker F, de Lera Alfonso M, Olivé-Gadea M, Farooqui M, Vivanco Suarez JS, Iezzi Z, Khalife J, Lechtenberg CG, Qadri SK, Moussa RB, Abdulrazzak MA, Almaghrabi TS, Mir O, Beharry J, Krishnaiah B, Miller M, Khalil N, Sharma GJ, Katsanos AH, Fadhil A, Duncan KR, Hu Y, Martin-Schild SB, Tsivgoulis GK, Cordato D, Furlan A, Churilov L, Mitchell PJ, Arthur AS, Parsons MW, Grotta JC, Sitton CW, Ribo M, Albers GW, Campbell BCV. Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well: The SELECT Late Study. JAMA Neurol 2023; 80:172-182. [PMID: 36574257 PMCID: PMC9857518 DOI: 10.1001/jamaneurol.2022.4714] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [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: 07/30/2022] [Accepted: 10/27/2022] [Indexed: 12/28/2022]
Abstract
Importance The role of endovascular thrombectomy is uncertain for patients presenting beyond 24 hours of the time they were last known well. Objective To evaluate functional and safety outcomes for endovascular thrombectomy (EVT) vs medical management in patients with large-vessel occlusion beyond 24 hours of last known well. Design, Setting, and Participants This retrospective observational cohort study enrolled patients between July 2012 and December 2021 at 17 centers across the United States, Spain, Australia, and New Zealand. Eligible patients had occlusions in the internal carotid artery or middle cerebral artery (M1 or M2 segment) and were treated with EVT or medical management beyond 24 hours of last known well. Interventions Endovascular thrombectomy or medical management (control). Main Outcomes and Measures Primary outcome was functional independence (modified Rankin Scale score 0-2). Mortality and symptomatic intracranial hemorrhage (sICH) were safety outcomes. Propensity score (PS)-weighted multivariable logistic regression analyses were adjusted for prespecified clinical characteristics, perfusion parameters, and/or Alberta Stroke Program Early CT Score (ASPECTS) and were repeated in subsequent 1:1 PS-matched cohorts. Results Of 301 patients (median [IQR] age, 69 years [59-81]; 149 female), 185 patients (61%) received EVT and 116 (39%) received medical management. In adjusted analyses, EVT was associated with better functional independence (38% vs control, 10%; inverse probability treatment weighting adjusted odds ratio [IPTW aOR], 4.56; 95% CI, 2.28-9.09; P < .001) despite increased odds of sICH (10.1% for EVT vs 1.7% for control; IPTW aOR, 10.65; 95% CI, 2.19-51.69; P = .003). This association persisted after PS-based matching on (1) clinical characteristics and ASPECTS (EVT, 35%, vs control, 19%; aOR, 3.14; 95% CI, 1.02-9.72; P = .047); (2) clinical characteristics and perfusion parameters (EVT, 35%, vs control, 17%; aOR, 4.17; 95% CI, 1.15-15.17; P = .03); and (3) clinical characteristics, ASPECTS, and perfusion parameters (EVT, 45%, vs control, 21%; aOR, 4.39; 95% CI, 1.04-18.53; P = .04). Patients receiving EVT had lower odds of mortality (26%) compared with those in the control group (41%; IPTW aOR, 0.49; 95% CI, 0.27-0.89; P = .02). Conclusions and Relevance In this study of treatment beyond 24 hours of last known well, EVT was associated with higher odds of functional independence compared with medical management, with consistent results obtained in PS-matched subpopulations and patients with presence of mismatch, despite increased odds of sICH. Our findings support EVT feasibility in selected patients beyond 24 hours. Prospective studies are warranted for confirmation.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Timothy J. Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, Texas
| | | | | | - Michael G. Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Nathan W. Manning
- Department of Neurosurgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - James E. Siegler
- Department of Neurology, Cooper Neurological Institute, Camden, New Jersey
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis
| | - Laith Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Spiros Blackburn
- Department of Neurosurgery, University of Texas Health Sciences Center, Houston
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jordi Blasco
- Department of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Arturu Renú
- Department of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Navdeep S. Sangha
- Department of Neurology, Stroke and Telestroke, Kaiser Permanente, Los Angeles, California
| | - Juan F. Arenillas
- Department of Neurology, Hospital Clínico Universitario – University of Valladolid, Valladolid, Spain
| | | | - Adam Wallace
- Department of Neurointerventional Surgery, Ascension Wisconsin, Milwaukee
| | - Daniel Gibson
- Department of Neurointerventional Surgery, Ascension Wisconsin, Milwaukee
| | - Deep K. Pujara
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Faris Shaker
- Department of Neurosurgery, University of Texas Health Sciences Center, Houston
| | - Mercedes de Lera Alfonso
- Department of Neurology, Hospital Clínico Universitario – University of Valladolid, Valladolid, Spain
| | - Marta Olivé-Gadea
- Department of Neurology, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Mudassir Farooqui
- Neurointerventional Research Lab, University of Iowa Hospitals and Clinics, Iowa City
| | | | - Zachary Iezzi
- Department of Neurology, Cooper Neurological Institute, Camden, New Jersey
| | - Jane Khalife
- Department of Neurology, Cooper Neurological Institute, Camden, New Jersey
| | | | - Syed K. Qadri
- Department of Neurology, University of Texas Health Sciences Center, Houston
| | - Rami B. Moussa
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | | | - Osman Mir
- Department of Neurology, Texas Stroke Institute, Dallas
| | - James Beharry
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Balaji Krishnaiah
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis
| | - Megan Miller
- Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Najwa Khalil
- Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Gagan J. Sharma
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Neurology, University of Melbourne, Parkville, Victoria, Australia
| | - Aristeidis H. Katsanos
- Department of Neurology, McMaster University and Population Health Research Institute, Toronto, Ontario, Canada
| | - Ali Fadhil
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kelsey R. Duncan
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Yin Hu
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Sheryl B. Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, Louisiana
| | - Georgios K. Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Dennis Cordato
- Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Anthony Furlan
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Leonid Churilov
- Department of Biostatistics, University of Melbourne, Parkville, Victoria, Australia
| | - Peter J. Mitchell
- Department of Radiology, NeuroIntervention Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Adam S. Arthur
- Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee
| | - Mark W. Parsons
- Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - James C. Grotta
- Department of Neurology, Memorial Hermann Hospital – Texas Medical Center, Houston
| | - Clark W. Sitton
- Department of Radiology and Neuroradiology, University of Texas Health Sciences Center, Houston
| | - Marc Ribo
- Department of Neurology, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | | | - Bruce C. V. Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Olivé-Gadea M, Pérez de la Ossa N, Jovin T, Abilleira S, Jiménez X, Cardona P, Chamorro A, Flores A, Silva Y, Purroy F, Martí-Fabregas J, Rodríguez-Campello A, Zaragoza J, Krupinski J, Canovas D, Gomez Choco M, Mas N, Palomeras E, Cocho D, Aragonès JM, Repullo C, Sanjurjo E, Carrion D, Catena E, Costa X, Almendros MC, Barceló M, Monedero J, Rybyeva M, Diaz G, Ribó M. Evolution of quality indicators in acute stroke during the RACECAT Trial: Impact in the general population. Int J Stroke 2023; 18:229-236. [PMID: 35373657 DOI: 10.1177/17474930221093523] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute ischemic stroke patients not referred directly to a comprehensive stroke center (CSC) have reduced access to endovascular treatment (EVT). The RACECAT trial is a population-based cluster-randomized trial, designed to compare mothership and drip-and-ship strategies in acute ischemic stroke patients outside the catchment area of a CSC. AIMS To analyze the evolution of performance indicators in the regions that participated in RACECAT. METHODS This retrospective longitudinal observational study included all stroke alerts evaluated by emergency medical services in Catalonia between February 2016 and February 2020. Cases were classified geographically according to the nearest SC: local SC (Local-SC) and CSC catchment areas. We analyzed the evolution of EVT rates and relevant workflow times in Local-SC versus CSC catchment areas over three study periods: P1 (February 2016 to April 2017: before RACECAT initiation), P2 (May 2017 to September 2018), and P3 (October 2018 to February 2020). RESULTS We included 20603 stroke alerts, 10,694 (51.9%) of which were activated within Local-SC catchment areas. The proportion of patients receiving EVT within Local-SC catchment areas increased (P1 vs. P3: 7.5% (95% confidence interval (CI), 6.4-8.7) to 22.5% (95% CI, 20.8-24.4) p < 0.001). Inequalities in the odds of receiving EVT were reduced for patients from CSC versus Local-SC catchment areas (P1: odds ratio (OR) 3.9 (95% CI, 3.2-5) vs. P3: OR 1.5 (95% CI, 1.3-1.7) In Local-SC, door-to-image (P1: 24 (interquartile range (IQR) 15-36), P2: 24 (15-35), P3: 21 (13-32) min, p < 0.001) and door-to-needle times (P1: 42 (31-60), P2: 41 (29-58), P3: 35 (25-50) p < 0.001) reduced. Time from Local-SC arrival to groin puncture also decreased over time (P1: 188 [151-229], P2: 190 (157-233), P3: 168 (127-215) min, p < 0.001). CONCLUSION An increase in EVT rates in Local-SC regions with a significant decrease in workflow times occurred during the period of the RACECAT trial.
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Affiliation(s)
- Marta Olivé-Gadea
- Stroke Unit, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Tudor Jovin
- Neurology Department, Cooper University Health Care, Camden, NJ, USA
| | - Sonia Abilleira
- Stroke Program, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Xavier Jiménez
- Emergency Medical Services of Catalonia, Barcelona, Spain
| | - Pere Cardona
- Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | | | - Alan Flores
- Stroke Unit, Hospital Joan XIII, Tarragona, Spain
| | | | | | | | | | - Josep Zaragoza
- Neurology Department, Hospital Verge de la Cinta, Tortosa, Spain
| | - Jerzy Krupinski
- Neurology Department, Hospital Mútua Terrassa, Terrassa, Spain
| | - David Canovas
- Neurology Department, Hospital Parc Tauli, Sabadell, Spain
| | | | - Natalia Mas
- Neurology Department, Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | | | - Dolores Cocho
- Neurology Department, Hospital General de Granollers, Granollers, Spain
| | | | - Carmen Repullo
- Neurology Department, Fundació Sant Hospital, La Seu d'Urgell, Spain
| | - Eduard Sanjurjo
- Neurology Department, Hospital Comarcal del Pallars, Tremp, Spain
| | - Dolores Carrion
- Emergency Department, Hospital de Móra d'Ebre, Móra d'Ebre, Spain
| | - Esther Catena
- Neurology Department, Consorci Sanitari Alt Penedès-Garraf, Spain
| | - Xavier Costa
- Emergency Department, Hospital de Figueres, Figueres, Spain
| | | | - Miquel Barceló
- Emergency Department, Hospital de Cerdanya, Puigcerdà, Spain
| | | | | | - Gloria Diaz
- Emergency Department, Hospital de Campdevànol, Campdevànol, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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Rodrigo-Gisbert M, Requena M, De Dios Lascuevas M, García-Tornel Á, Olivé-Gadea M, Boned S, Muchada M, Deck M, Rodríguez-Villatoro N, Rodríguez-Luna D, Juega J, Pagola J, Tomasello A, Piñana C, Hernández D, Coscojuela P, Ribó M, Molina CA, Rubiera M. Multiparametric Neuroimaging and Its Association with Non-Contrast Computed Tomography in Late-Window Large Vessel Occlusion Acute Stroke. Cerebrovasc Dis 2022; 52:344-352. [PMID: 36318888 DOI: 10.1159/000526477] [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: 02/18/2022] [Accepted: 07/20/2022] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION Endovascular treatment (EVT) for acute ischemic stroke (AIS) between 6 and 24 h is established as a standard of care among patients selected by multiparametric neuroimaging. We aimed to explore neuroimaging parameters in late-window large vessel occlusion (LVO) patients and its association with non-contrast computed tomography (NCCT) findings. METHODS We included consecutive AIS patients within 6-24 h from the symptoms onset with LVO. We described multiparametric imaging findings, the rate of patients who fulfilled imaging perfusion criteria according to the DAWN and DEFUSE-3 trials that define the computed tomography perfusion mismatch (CTP-MM) group and its association with NCCT focused on Alberta Stroke Program Early CT Score (ASPECTS). We also analyzed the association between neuroimaging parameters and the clinical outcome determined by the 90-day modified Rankin scale (mRS). RESULTS We included 206 patients, of them, 176 (85.4%) presented CTP-MM and 184 (89.3%) presented an ASPECTS ≥6 on admission. The rate of CTP-MM was 90.8% in patients with ASPECTS ≥6, compared with 40.9% in those with low ASPECTS. ASPECTS was moderately correlated with ischemic core determined by cerebral blood flow <30% volume (rS = -0.557, p < 0.001). In EVT-treated patients (185, 89.8%), after adjusting for identifiable confounders, the presence of CTP-MM was a predictor of 90-day functional independence (OR: 3.38; 95% CI: 1.01-11.29; p = 0.048). We did not find an association between CTP-MM and 90-day functional disability (ordinal mRS shift, aOR: 1.39; 95% CI: 0.58-3.34; p = 0.459). CONCLUSIONS A great majority of patients who presented a LVO in the late window fulfilled guidelines imaging criteria to undergo EVT, especially those with high ASPECTS (≥6). Our data suggest that NCCT with CT angiography could be a reasonable approach for AIS treatment selection also in the late window.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain,
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta De Dios Lascuevas
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sandra Boned
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matías Deck
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Rodríguez-Luna
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesús Juega
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Tomasello
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Piñana
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Hernández
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pilar Coscojuela
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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15
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Garcia-Tornel A, Millan M, Rubiera M, Bustamante A, Requena M, Dorado L, Olivé-Gadea M, Jiménez X, Soto A, Querol M, Hernández-Pérez M, Gomis M, Cardona P, Urra X, Purroy F, Silva Y, Ustrell X, Esteve P, Salvat-Plana M, Gallofré M, Molina C, Dávalos A, Jovin T, Abilleira S, Ribo M, Pérez de la Ossa N. Workflows and Outcomes in Patients With Suspected Large Vessel Occlusion Stroke Triaged in Urban and Nonurban Areas. Stroke 2022; 53:3728-3740. [PMID: 36259411 DOI: 10.1161/strokeaha.122.040768] [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: 11/16/2022]
Abstract
BACKGROUND We aim to compare the outcome of patients from urban areas, where the referral center is able to perform thrombectomy, with patients from nonurban areas enrolled in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion). METHODS Patients with suspected large vessel occlusion stroke, as evaluated by a Rapid Arterial Occlusion Evaluation score of ≥5, from urban catchment areas of thrombectomy-capable centers during RACECAT trial enrollment period were included in the Stroke Code Registry of Catalonia. Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with an ischemic stroke. Secondary outcomes included mortality at 90 days, rate of thrombolysis and thrombectomy, time from onset to thrombolysis, and thrombectomy initiation. Propensity score matching was used to assemble a cohort of patients with similar characteristics. RESULTS The analysis included 1369 patients from nonurban areas and 2502 patients from urban areas. We matched 920 patients with an ischemic stroke from urban areas and nonurban areas based on their propensity scores. Patients with ischemic stroke from nonurban areas had higher degrees of disability at 90 days (median [interquartle range] modified Rankin Scale score, 3 [2-5] versus 3 [1-5], common odds ratio, 1.25 [95% CI, 1.06-1.48]); the observed average effect was only significant in patients with large vessel stroke (common odds ratio, 1.36 [95% CI, 1.08-1.65]). Mortality rate was similar between groups(odds ratio, 1.02 [95% CI, 0.81-1.28]). Patients from nonurban areas had higher odds of receiving thrombolysis (odds ratio, 1.36 [95% CI, 1.16-1.67]), lower odds of receiving thrombectomy(odds ratio, 0.61 [95% CI, 0.51-0.75]), and longer time from stroke onset to thrombolysis (mean difference 38 minutes [95% CI, 25-52]) and thrombectomy(mean difference 66 minutes [95% CI, 37-95]). CONCLUSIONS In Catalonia, Spain, patients with large vessel occlusion stroke triaged in nonurban areas had worse neurological outcomes than patients from urban areas, where the referral center was able to perform thrombectomy. Interventions aimed at improving organizational practices and the development of thrombectomy capabilities in centers located in remote areas should be pursued. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02795962.
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Affiliation(s)
- Alvaro Garcia-Tornel
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d'Hebrón, Barcelona, Spain (A.G.-T., M. Rubiera, M. Requena, M.O.-G., C.M., M. Ribo)
| | - Monica Millan
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.M., A.B., L.D., M.G., D.A., N.P.d.l.O.)
| | - Marta Rubiera
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d'Hebrón, Barcelona, Spain (A.G.-T., M. Rubiera, M. Requena, M.O.-G., C.M., M. Ribo)
| | - Alejandro Bustamante
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.M., A.B., L.D., M.G., D.A., N.P.d.l.O.)
| | - Manuel Requena
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d'Hebrón, Barcelona, Spain (A.G.-T., M. Rubiera, M. Requena, M.O.-G., C.M., M. Ribo)
| | - Laura Dorado
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.M., A.B., L.D., M.G., D.A., N.P.d.l.O.)
| | - Marta Olivé-Gadea
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d'Hebrón, Barcelona, Spain (A.G.-T., M. Rubiera, M. Requena, M.O.-G., C.M., M. Ribo)
| | - Xavier Jiménez
- Emergency Medical Services of Catalonia, Barcelona, Spain (X.J., A.S., M.Q.)
| | - Angels Soto
- Emergency Medical Services of Catalonia, Barcelona, Spain (X.J., A.S., M.Q.)
| | - Marisol Querol
- Emergency Medical Services of Catalonia, Barcelona, Spain (X.J., A.S., M.Q.)
| | | | - Meritxell Gomis
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.M., A.B., L.D., M.G., D.A., N.P.d.l.O.)
| | - Pere Cardona
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain (P.C.)
| | - Xabier Urra
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain (X.U.)
| | - Francesc Purroy
- Department of Neurology, Stroke Unit, Hospital Arnau de Vilanova de Lleida, Lleida, IRBLleida, UdL, Spain (F.P.)
| | - Yolanda Silva
- Department of Neurology, Stroke Unit, Hospital Josep Trueta, Girona, Spain (Y.S.)
| | - Xavier Ustrell
- Department of Neurology, Stroke Unit, Hospital Joan XXIII, Tarragona, Spain (X.U.)
| | - Patricia Esteve
- Department of Neurology, Stroke Unit, Hospital Verge de la Cinta, Tortosa, Spain (P.E.)
| | - Mercè Salvat-Plana
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (M.S.-P., N.P.d.l.O.)
| | | | - Carlos Molina
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d'Hebrón, Barcelona, Spain (A.G.-T., M. Rubiera, M. Requena, M.O.-G., C.M., M. Ribo)
| | | | - Tudor Jovin
- Neurological Institute, Cooper University Hospital, Camden, New Jersey (T.J.)
| | | | - Marc Ribo
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d'Hebrón, Barcelona, Spain (A.G.-T., M. Rubiera, M. Requena, M.O.-G., C.M., M. Ribo)
| | - Natalia Pérez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (M.M., A.B., L.D., M.G., D.A., N.P.d.l.O.).,Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (M.S.-P., N.P.d.l.O.)
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16
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Sarraj A, Albers GW, Blasco J, Arenillas JF, Ribo M, Hassan AE, de la Ossa NP, Wu TYH, Cardona Portela P, Abraham MG, Chen M, Maali L, Kleinig TJ, Cordato D, Wallace AN, Schaafsma JD, Sangha N, Gibson DP, Blackburn SL, De Lera Alfonso M, Pujara D, Shaker F, McCullough-Hicks ME, Moreno Negrete JL, Renu A, Beharry J, Cappelen-Smith C, Rodríguez-Esparragoza L, Olivé-Gadea M, Requena M, Almaghrabi T, Mendes Pereira V, Sitton C, Martin-Schild S, Song S, Ma H, Churilov L, Mitchell PJ, Parsons MW, Furlan A, Grotta JC, Donnan GA, Davis SM, Campbell BCV. Thrombectomy versus Medical Management in Mild Strokes due to Large Vessel Occlusion: Exploratory Analysis from the EXTEND-IA Trials and a Pooled International Cohort. Ann Neurol 2022; 92:364-378. [PMID: 35599458 DOI: 10.1002/ana.26418] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate functional and safety outcomes for endovascular thrombectomy (EVT) versus medical management (MM) in patients with large vessel occlusion (LVO) and mild neurological deficits, stratified by perfusion imaging mismatch. METHODS The pooled cohort consisted of patients with National Institutes of Health Stroke Scale (NIHSS) < 6 and internal carotid artery (ICA), M1, or M2 occlusions from the Extending the Time for Thrombolysis in Emergecy Neurological Deficits - Intra-Arterial (EXTEND-IA) Trial, Tenecteplase vs Alteplase before Endovascular Thrombectomy in Ischemic Stroke (EXTEND-IA TNK) trials Part I/II and prospective data from 15 EVT centers from October 2010 to April 2020. RAPID software estimated ischemic core and mismatch. Patients receiving primary EVT (EVTpri ) were compared to those who received primary MM (MMpri ), including those who deteriorated and received rescue EVT, in overall and propensity score (PS)-matched cohorts. Patients were stratified by target mismatch (mismatch ratio ≥ 1.8 and mismatch volume ≥ 15ml). Primary outcome was functional independence (90-day modified Rankin Scale = 0-2). Secondary outcomes included safety (symptomatic intracerebral hemorrhage [sICH], neurological worsening, and mortality). RESULTS Of 540 patients, 286 (53%) received EVTpri and demonstrated larger critically hypoperfused tissue (Tmax > 6 seconds) volumes (median [IQR]: 64 [26-96] ml vs MMpri : 40 [14-76] ml, p < 0.001) and higher presentation NIHSS (median [IQR]: 4 [2-5] vs MMpri : 3 [2-4], p < 0.001). Functional independence was similar (EVTpri : 77.4% vs MMpri : 75.6%, adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] = 0.82-2.03, p = 0.27). EVT had worse safety regarding sICH (EVTpri : 16.3% vs MMpri : 1.3%, p < 0.001) and neurological worsening (EVTpri : 19.6% vs MMpri : 6.7%, p < 0.001). In 414 subjects (76.7%) with target mismatch, EVT was associated with improved functional independence (EVTpri : 77.4% vs MMpri : 72.7%, aOR = 1.68, 95% CI = 1.01-2.81, p = 0.048), whereas there was a trend toward less favorable outcomes with primary EVT (EVTpri : 77.4% vs MMpri : 83.3%, aOR = 0.39, 95% CI = 0.12-1.34, p = 0.13) without target mismatch (pinteraction = 0.06). Similar findings were observed in a propensity score-matched subpopulation. INTERPRETATION Overall, EVT was not associated with improved clinical outcomes in mild strokes due to LVO, and sICH was increased. However, in patients with target mismatch profile, EVT was associated with increased functional independence. Perfusion imaging may be helpful to select mild stroke patients for EVT. ANN NEUROL 2022;92:364-378.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | | | - Jordi Blasco
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Juan F Arenillas
- Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX, USA
| | | | - Teddy Yuan-Hao Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Laith Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis Cordato
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Joanna D Schaafsma
- Neurology, Department of Internal Medicine, Toronto Western Hospital-University Health Network, Toronto, ON, Canada
| | - Navdeep Sangha
- Department of Neurology, Kaiser Permanente, Los Angeles, CA, USA
| | - Daniel P Gibson
- Department of Neurosurgery, Ascension Wisconsin, Milwaukee, WI, USA
| | - Spiros L Blackburn
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, TX, USA
| | | | - Deep Pujara
- Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | - Faris Shaker
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, TX, USA
| | | | | | - Arturo Renu
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - James Beharry
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Cecilia Cappelen-Smith
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Tareq Almaghrabi
- Department of Internal Medicine, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
| | | | - Clark Sitton
- Department of Diagnostic and Interventional Radiology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Sheryl Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, LA, USA
| | - Sarah Song
- Department of Neurology, Rush University Medical Center, Chicago, IL, USA
| | - Henry Ma
- Department of Neurology, Monash University, Melbourne, Vic., Australia
| | - Leonid Churilov
- Department of Biostatistics, University of Melbourne, Parkville, Vic., Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, Parkville, Vic., Australia
| | - Mark W Parsons
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | - Anthony Furlan
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | - James C Grotta
- Department of Clinical Innovation and Research, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
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17
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Mujanovic A, Kurmann CC, Dobrocky T, Olivé-Gadea M, Maegerlein C, Pierot L, Mendes Pereira V, Costalat V, Psychogios M, Michel P, Beyeler M, Piechowiak EI, Seiffge DJ, Mordasini P, Arnold M, Gralla J, Fischer U, Kaesmacher J, Meinel TR. Bridging intravenous thrombolysis in patients with atrial fibrillation. Front Neurol 2022; 13:945338. [PMID: 35989924 PMCID: PMC9382124 DOI: 10.3389/fneur.2022.945338] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purpose 40% of acute ischemic stroke patients treated by mechanical thrombectomy (MT) have a clinical history of atrial fibrillation (AF). The safety of bridging intravenous thrombolysis (IVT) (MT + IVT) is currently being discussed. We aimed to analyze the interaction between oral anticoagulation (OAC) status or AF with bridging IVT, regarding the occurrence of symptomatic intracranial hemorrhage (sICH) and functional outcome. Materials and Methods Multicentric observational cohort study (BEYOND-SWIFT registry) of consecutive patients undergoing MT between 2010 and 2018 (n = 2,941). Multinomial regression models were adjusted for prespecified baseline and plausible pathophysiological covariates identified on a univariate analysis to assess the association of AF and OAC status with sICH and good outcomes (90-day modified Rankin Scale score 0–2). Results In the total cohort (median age 74, 50.6% women), 1,347 (45.8%) patients had AF. Higher admission National Institutes of Health Stroke Scale (NIHSS) score (aOR 1.04 [95% 1.02–1.06], per point of increase) and prior medication with Vitamin K antagonists (VKA) (aOR 2.19 [95% 1.27–3.66]) were associated with sICH. Neither AF itself (aOR 0.71 [95% 0.41–1.24]) nor bridging IVT (aOR 1.08 [0.67–1.75]) were significantly associated with increased sICH. Receiving bridging IVT (aOR 1.61 [95% 1.24–2.11]) was associated with good 90-day outcome, with no interaction between AF and IVT (p = 0.92). Conclusion Bridging IVT appears to be a reasonable clinical option in selected patients with AF. Given the increased sICH risk in patients with VKA, subgroup analysis of the randomized controlled trials should analyze whether patients with VKA might benefit from withholding bridging IVT. Registration clinicaltrials.gov; Unique identifier: NCT03496064.
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Affiliation(s)
- Adnan Mujanovic
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Christoph C. Kurmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Laurent Pierot
- Department of Neuroradiology, University Hospital Reims, Reims, France
| | - Vitor Mendes Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Montpellier, Montpellier, France
| | - Marios Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Morin Beyeler
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - David J. Seiffge
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- *Correspondence: Thomas R. Meinel
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18
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Garcia-Rodriguez N, Rodriguez S, Tejada PI, Miranda-Artieda ZM, Ridao N, Buxó X, Pérez-Mesquida ME, Beseler MR, Salom JB, Pérez LM, Inzitari M, Otero-Villaverde S, Martin-Mourelle R, Molleda M, Quintana M, Olivé-Gadea M, Penalba A, Rosell A. Functional Recovery and Serum Angiogenin Changes According to Intensity of Rehabilitation Therapy After Stroke. Front Neurol 2021; 12:767484. [PMID: 34899582 PMCID: PMC8655101 DOI: 10.3389/fneur.2021.767484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/22/2021] [Indexed: 12/05/2022] Open
Abstract
Background: Rehabilitation is still the only treatment available to improve functional status after the acute phase of stroke. Most clinical guidelines highlight the need to design rehabilitation treatments considering starting time, intensity, and frequency, according to the tolerance of the patient. However, there are no homogeneous protocols and the biological effects are under investigation. Objective: To investigate the impact of rehabilitation intensity (hours) after stroke on functional improvement and serum angiogenin (ANG) in a 6-month follow-up study. Methods: A prospective, observational, longitudinal, and multicenter study with three cohorts: strokes in intensive rehabilitation therapy (IRT, minimum 15 h/week) vs. conventional therapy (NO-IRT, <15 h/week), and controls subjects (without known neurological, malignant, or inflammatory diseases). A total of seven centers participated, with functional evaluations and blood sampling during follow-up. The final cohort includes 62 strokes and 43 controls with demographic, clinical, blood samples, and exhaustive functional monitoring. Results: The median (IQR) number of weekly hours of therapy was different: IRT 15 (15–16) vs. NO-IRT 7.5 (5–9), p < 0.01, with progressive and significant improvements in both groups. However, IRT patients showed earlier improvements (within 1 month) on several scales (CAHAI, FMA, and FAC; p < 0.001) and the earliest community ambulation achievements (0.89 m/s at 3 months). There was a significant difference in ANG temporal profile between the IRT and NO-IRT groups (p < 0.01). Additionally, ANG was elevated at 1 month only in the IRT group (p < 0.05) whereas it decreased in the NO-IRT group (p < 0.05). Conclusions: Our results suggest an association of rehabilitation intensity with early functional improvements, and connect the rehabilitation process with blood biomarkers.
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Affiliation(s)
- Nicolás Garcia-Rodriguez
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Unidad de Rehabilitación Neurológica y Daño Cerebral, Hospital Vall d'Hebron, Barcelona, Spain
| | - Susana Rodriguez
- Unidad de Rehabilitación Neurológica y Daño Cerebral, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | - Natalia Ridao
- Servei de Medicina Física i Rehabilitació, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Sabadell, Spain
| | - Xavi Buxó
- Unidad de Rehabilitación Neurológica y Daño Cerebral, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Maria Rosario Beseler
- Servicio de Medicina Física y Rehabilitación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Juan B Salom
- Unidad Mixta de Investigación Cerebrovascular, Instituto de Investigación Sanitaria La Fe-Universitat de Valencia, Valencia, Spain.,Departamento de Fisiología, Universidad de Valencia, Valencia, Spain
| | - Laura M Pérez
- RE-FiT Barcelona Research Group, Vall d'Hebron Institute of Research, Parc Sanitari Pere Virgili, Barcelona, Spain.,Parc Sanitari Pere Virgili, Area of Intermediate Care, Barcelona, Spain
| | - Marco Inzitari
- RE-FiT Barcelona Research Group, Vall d'Hebron Institute of Research, Parc Sanitari Pere Virgili, Barcelona, Spain.,Universitat Oberta de Catalunya, Barcelona, Spain
| | | | | | | | - Manuel Quintana
- Epilepsy Research Group and Epilepsy Unit, Vall d'Hebron Research Institute and Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Anna Penalba
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Rosell
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
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19
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Requena M, Olivé-Gadea M, Muchada M, Hernández D, Rubiera M, Boned S, Piñana C, Deck M, García-Tornel Á, Díaz-Silva H, Rodriguez-Villatoro N, Juega J, Rodriguez-Luna D, Pagola J, Molina C, Tomasello A, Ribo M. Direct to Angiography Suite Without Stopping for Computed Tomography Imaging for Patients With Acute Stroke: A Randomized Clinical Trial. JAMA Neurol 2021; 78:1099-1107. [PMID: 34338742 DOI: 10.1001/jamaneurol.2021.2385] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Direct transfer to angiography suite (DTAS) for patients with suspected large vessel occlusion (LVO) stroke has been described as an effective and safe measure to reduce workflow time in endovascular treatment (EVT). However, it is unknown whether DTAS improves long-term functional outcomes. Objective To explore the effect of DTAS on clinical outcomes among patients with LVO stroke in a randomized clinical trial. Design, Setting, and Participants The study was an investigator-initiated, single-center, evaluator-blinded randomized clinical trial. Of 466 consecutive patients with acute stroke screened, 174 with suspected LVO acute stroke within 6 hours of symptom onset were included. Enrollment took place from September 2018 to November 2020 and was stopped after a preplanned interim analysis. Final follow-up was in February 2021. Interventions Patients were randomly assigned (1:1) to follow either DTAS (89 patients) or conventional workflow (85 patients received direct transfer to computed tomographic imaging, with usual imaging performed and EVT indication decided) to assess the indication of EVT. Patients were stratified according to their having been transferred from a primary center vs having a direct admission. Main Outcomes and Measures The primary outcome was a shift analysis assessing the distribution of the 90-day 7-category (from 0 [no symptoms] to 6 [death]) modified Rankin Scale (mRS) score among patients with LVO whether or not they received EVT (modified intention-to-treat population) assessed by blinded external evaluators. Secondary outcomes included rate of EVT and door-to-arterial puncture time. Safety outcomes included 90-day mortality and rates of symptomatic intracranial hemorrhage. Results In total, 174 patients were included, with a mean (SD) age of 73.4 (12.6) years (range, 19-95 years), and 78 patients (44.8%) were women. Their mean (SD) onset-to-door time was 228.0 (117.9) minutes, and their median admission National Institutes of Health Stroke Scale score was 18 (interquartile range [IQR], 14-21). In the modified intention-to-treat population, EVT was performed for all 74 patients in the DTAS group and for 64 patients (87.7%) in the conventional workflow group (P = .002). The DTAS protocol decreased the median door-to-arterial puncture time (18 minutes [IQR, 15-24 minutes] vs 42 minutes [IQR, 35-51 minutes]; P < .001) and door-to-reperfusion time (57 minutes [IQR, 43-77 minutes] vs 84 minutes [IQR, 63-117 minutes]; P < .001). The DTAS protocol decreased the severity of disability across the range of the mRS (adjusted common odds ratio, 2.2; 95% CI, 1.2-4.1; P = .009). Safety variables were comparable between groups. Conclusions and Relevance For patients with LVO admitted within 6 hours after symptom onset, this randomized clinical trial found that, compared with conventional workflow, the use of DTAS increased the odds of patients undergoing EVT, decreased hospital workflow time, and improved clinical outcome. Trial Registration ClinicalTrials.gov Identifier: NCT04001738.
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Affiliation(s)
- Manuel Requena
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Marta Olivé-Gadea
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Marian Muchada
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - David Hernández
- Neurorradiologia Intervencionista, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marta Rubiera
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Sandra Boned
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Carlos Piñana
- Neurorradiologia Intervencionista, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Matías Deck
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Álvaro García-Tornel
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Humberto Díaz-Silva
- Neurorradiologia Intervencionista, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Noelia Rodriguez-Villatoro
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Jesús Juega
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - David Rodriguez-Luna
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Jorge Pagola
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Carlos Molina
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
| | - Alejandro Tomasello
- Neurorradiologia Intervencionista, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Ribo
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Grup de Recerca en Ictus, Vall d'Hebron Insitut de Recerca, Barcelona, Spain
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20
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García-Tornel Á, Campos D, Rubiera M, Boned S, Olivé-Gadea M, Requena M, Ciolli L, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Sanjuan E, Tomasello A, Piñana C, Hernández D, Álvarez-Sabin J, Molina CA, Ribó M. Ischemic Core Overestimation on Computed Tomography Perfusion. Stroke 2021; 52:1751-1760. [PMID: 33682453 DOI: 10.1161/strokeaha.120.031800] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Álvaro García-Tornel
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Daniel Campos
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Sandra Boned
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Ludovico Ciolli
- Stroke Unit, Neurology Unit, Department of Neuroscience, Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Italy (L.C.)
| | - Marian Muchada
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Matias Deck
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Jesus Juega
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Estela Sanjuan
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Alejandro Tomasello
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Carlos Piñana
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - David Hernández
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - José Álvarez-Sabin
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
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21
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Kaesmacher J, Meinel TR, Nannoni S, Olivé-Gadea M, Piechowiak EI, Maegerlein C, Goeldlin M, Pierot L, Seiffge DJ, Mendes Pereira V, Heldner MR, Grunder L, Costalat V, Arnold M, Dobrocky T, Gralla J, Mordasini P, Fischer U. Bridging May Increase the Risk of Symptomatic Intracranial Hemorrhage in Thrombectomy Patients With Low Alberta Stroke Program Early Computed Tomography Score. Stroke 2021; 52:1098-1104. [PMID: 33504188 DOI: 10.1161/strokeaha.120.030508] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Whether intravenous thrombolysis (IVT) increases the risk for symptomatic intracranial hemorrhage (sICH) in patients treated with mechanical thrombectomy (MT) is a matter of debate. Purpose of this study was to evaluate the extent of early ischemia as a possible factor influencing the risk for sICH after IVT+MT versus direct MT. METHODS An explorative analysis of the BEYOND-SWIFT (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy) multicenter cohort was performed. We hypothesized that the sICH risk between IVT+MT versus direct MT differs across the strata of Alberta Stroke Program Early CT Scores (ASPECTS). For this purpose, all patients with ICA, M1, and M2 vessel occlusions and available noncontrast computed tomography or diffusion-weighed imaging ASPECTS (n=2002) were analyzed. We used logistic regression analysis in subgroups, as well as interaction terms, to address the risk of sICH in IVT+MT versus direct MT patients across the ASPECTS strata. RESULTS In 2002 patients (median age, 73.7 years; 50.7% women; median National Institutes of Health Stroke Scale score, 16), the overall rate of sICH was 6.5% (95% CI, 5.5%-7.7%). Risk of sICH differed across ASPECTS groups (9-10: 6.3%; 6-8: 5.6% and ≤5 9.8%; P=0.042). With decreasing ASPECTS, the risks of sICH in the IVT+MT versus the direct MT group increased from adjusted odds ratio of 0.61 ([95% CI, 0.24-1.60] ASPECTS 9-10), to 1.72 ([95% CI, 0.69-4.24] ASPECTS 6-8) and 6.31 ([95% CI, 1.87-21.29] ASPECTS ≤5), yielding a positive interaction term (1.91 [95% CI, 1.01-3.63]). Sensitivity analyses regarding diffusion-weighed imaging versus noncontrast computed tomography ASPECTS did not alter the primary observations. CONCLUSIONS The extent of early ischemia may influence relative risks of sICH in IVT+MT versus direct MT patients, with an excess sICH risk in IVT+MT patients with low ASPECTS. If confirmed in post hoc analyses of randomized controlled trial data, IVT may be administered more carefully in patients with low ASPECTS eligible for and with direct access to MT.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic and Interventional and Pediatric Radiology (J.K., L.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Stefania Nannoni
- Stroke Centre and Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (S.N.)
| | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M.O.-G.)
| | - Eike I Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M.)
| | - Martina Goeldlin
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | | | - David J Seiffge
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Vitor Mendes Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, ON, Canada (V.M.P.)
| | - Mirjam R Heldner
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Lorenz Grunder
- University Institute of Diagnostic and Interventional and Pediatric Radiology (J.K., L.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | | | - Marcel Arnold
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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22
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Olivé-Gadea M, Requena M, Campos D, Garcia-Tornel A, Deck M, Muchada M, Boned S, Rodríguez N, Juega J, Rodríguez-Luna D, Pagola J, Rubiera M, Hernández-Jiménez M, Molina CA, Ribo M. Defining a Target Population to Effectively Test a Neuroprotective Drug. Stroke 2021; 52:505-510. [PMID: 33423513 DOI: 10.1161/strokeaha.120.032025] [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 We aim to identify the subgroup of acute ischemic stroke patients with higher probabilities of benefiting from a potential neuroprotective drug using baseline outcome predictors and test whether different selection criteria strategies can improve detected treatment effect. METHODS We analyzed the association between final infarct volume (FIV), measured on 24- to 72-hour computed tomography, and National Institutes of Health Stroke Scale at discharge/day 5 of acute stroke patients who underwent endovascular treatment. Models were adjusted for age, sex, and affected hemisphere. We analyzed the impact of absolute (5-15 mL) and relative (33%) FIV reductions in the National Institutes of Health Stroke Scale in the whole population and in different subsets of patients selected according to baseline imaging criteria using computed tomography perfusion. RESULTS We analyzed 627 patients; association between FIV and 5-day National Institutes of Health Stroke Scale was best described with a quadratic function, with a regression coefficient β=1.56 ([95% CI, 1.45-1.67] P<0.001) in the adjusted analysis. In the models considering a fixed absolute (5/15 mL) FIV reduction, treatment effect was highest when patients with predicted larger FIV were excluded, whereas in a 33% FIV reduction model, treatment effect increased with the exclusion of patients with expected excellent outcomes. CONCLUSIONS Patients either with excellent outcomes after endovascular thrombectomy or with large infarcts may dilute the treatment effect in stroke neuroprotective drug trials. Computed tomography perfusion on admission may help selecting adequate patients according to expected drug effect profile.
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Affiliation(s)
- Marta Olivé-Gadea
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Manuel Requena
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Daniel Campos
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Alvaro Garcia-Tornel
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Matías Deck
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Marian Muchada
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Sandra Boned
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Noelia Rodríguez
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Jesús Juega
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - David Rodríguez-Luna
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Jorge Pagola
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Marta Rubiera
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | | | - Carlos A Molina
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
| | - Marc Ribo
- Stroke Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo).,Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.O.-G., M. Requena, D.C., A.G.-T., M.D., M.M., S.B., N.R., J.J., D.R.-L., J.P., M. Rubiera, C.A.M., M. Ribo)
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23
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Campos-Fernández D, Fonseca E, Olivé-Gadea M, Quintana M, Abraira L, Seijo-Raposo I, Santamarina E, Toledo M. The mediating role of epileptic seizures, irritability, and depression on quality of life in people with epilepsy. Epilepsy Behav 2020; 113:107511. [PMID: 33129044 DOI: 10.1016/j.yebeh.2020.107511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE Psychiatric comorbidity is common in epilepsy and has a considerable impact on patient quality of life (QoL). This study aimed to analyze the relationship between seizure frequency, irritability, and depression and describe how they mediate each other's effect on QoL in epilepsy. METHODS This is a cross-sectional study of consecutive adults seen at an outpatient epilepsy clinic of a tertiary hospital in Barcelona, Spain. All the patients were evaluated for psychiatric comorbidity and administered the State-Trait Anger Expression Inventory-2 (STAXI-2), the Hospital Anxiety and Depression Scale (HADS), and the Quality Of Life in Epilepsy Inventory-10 (QOLIE-10). Mediation analysis with multiple linear regression followed by the Sobel test was performed. RESULTS We studied 157 patients. Seizure frequency (R = -0.193, P = .053), irritability (R = 0.216, P = .039), and depression (R = -0.598, P < .001) had all a negative effect on QoL. In the adjusted linear regression model, depression was the only independent predictor of impaired QoL (B = -2.453 [95% confidence interval (CI): -3.161, -1.744], P < .001). The Sobel test showed that depression exerted a significant mediating effect on seizure frequency (Z = -1.984; P = .047) and irritability (Z = -3.669; P < .001) in their influence on QoL. CONCLUSION Depression is an independent predictor of worse QoL and significantly mediated the effects of irritability and poor seizure control on QoL impairment in patients with epilepsy.
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Affiliation(s)
- Daniel Campos-Fernández
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Elena Fonseca
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg Vall d'Hebron 119-129, 08035 Barcelona, Spain; Medicine Department, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain.
| | - Marta Olivé-Gadea
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg Vall d'Hebron 119-129, 08035 Barcelona, Spain; Medicine Department, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Iván Seijo-Raposo
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg Vall d'Hebron 119-129, 08035 Barcelona, Spain; Medicine Department, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg Vall d'Hebron 119-129, 08035 Barcelona, Spain; Medicine Department, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
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García-Tornel Á, Ciolli L, Rubiera M, Requena M, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Boned S, Olivé-Gadea M, Sanjuan E, Tomasello A, Piñana C, Hernández D, Álvarez-Sabin J, Molina CA, Ribó M. Leptomeningeal Collateral Flow Modifies Endovascular Treatment Efficacy on Large-Vessel Occlusion Strokes. Stroke 2020; 52:299-303. [PMID: 33250040 DOI: 10.1161/strokeaha.120.031338] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We aim to evaluate if good collateral flow (CF) modifies endovascular therapy (EVT) efficacy on large-vessel stroke. To do that, we used final degree of reperfusion and number of device-passes performed, factors previously associated with better functional outcome, as main outcome measures. METHODS Single-center retrospective study including consecutive stroke patients receiving EVT for anterior circulation large-vessel stroke. CF degree was assessed on CT angiography before EVT using a previously validated 4-grade score. Final degree of reperfusion, using modified Thrombolysis in Cerebral Ischemia (mTICI), and number of device-passes performed were prospectively collected. Multivariable analysis was performed to evaluate the influence of collateral flow degree on final degree of reperfusion and number of device-passes performed. RESULTS Six hundred twenty-six patients were included in the study; 369 patients (59%) presented good collateral flow on CT angiography. Five hundred twenty-two patients (84%) achieved successful reperfusion (mTICI 2B-3) after EVT, 304 (48%) of them with a final mTICI 2C-3. Median number of device-passes was 2 (interquartile range, 1-3). Good CF was independently associated with better final degree of reperfusion (shift analysis for mTICI0-2A/2B/2C-3%, poor CF 19/38/43 versus good CF 15/32/53, adjusted odds ratio, 1.51 [95% CI, 1.08-2.11]). Poor CF was independently associated with higher number of device-passes performed to achieve successful reperfusion (mTICI2B-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.59, [95% CI, 1.09-2.31]) and complete reperfusion (mTICI2C-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.70 [95% CI, 1.04-2.90]). CONCLUSIONS Patients with good CF treated with EVT experience higher rates of successful reperfusion with lower number of device-passes. CF may facilitate thrombus retrieval and prevent distal embolization of clot fragments, improving device-passes efficacy.
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Affiliation(s)
- Álvaro García-Tornel
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ludovico Ciolli
- Stroke Unit, Neurology Unit, Department of Neuroscience, Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Italy (L.C.)
| | - Marta Rubiera
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matias Deck
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesus Juega
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sandra Boned
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Estela Sanjuan
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Tomasello
- Department of Neuroradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Piñana
- Department of Neuroradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Hernández
- Department of Neuroradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Álvarez-Sabin
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L, M.D., J.J., N.R.-V., S.B., M.O.-G., E.S., J.A.-S., C.A.M., M. Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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Meinel TR, Kaesmacher J, Mosimann PJ, Seiffge D, Jung S, Mordasini P, Arnold M, Goeldlin M, Hajdu SD, Olivé-Gadea M, Maegerlein C, Costalat V, Pierot L, Schaafsma JD, Fischer U, Gralla J. Association of initial imaging modality and futile recanalization after thrombectomy. Neurology 2020; 95:e2331-e2342. [PMID: 32847948 PMCID: PMC7682915 DOI: 10.1212/wnl.0000000000010614] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FRs) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT [Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy], NCT03496064). Methods In 2,011 patients (49.7% female, median age 73 years [61–81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FRs were defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization in patients selected by MRI (n = 690) and CT (n = 1,321) with a sensitivity analysis considering only patients with mRS 5–6 as futile. Results MRI as compared to CT resulted in similar rates of subsequent MT (adjusted odds ratio [aOR] 1.048, 95% confidence interval [CI] 0.677–1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4–6 including 393/1,489 (26%) FR mRS 5–6. CT-based selection was associated with increased rates of FRs compared to MRI (44% [41%–47%] vs 29% [25%–32%], p < 0.001; aOR 1.77 [95% CI 1.25–2.51]). These findings were robust in sensitivity analysis. MRI-selected patients had a delay of approximately 30 minutes in workflow metrics in real-world university comprehensive stroke centers. However, functional outcome and mortality were more favorable in patients selected by MRI compared to patients selected with CT. Conclusions CT selection for MT was associated with an increased risk of FRs as compared to MRI selection. Efforts are needed to shorten workflow delays in MRI patients. Further research is needed to clarify the role of the initial imaging modality on FR occurrence and to develop a reliable FR prediction algorithm.
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Affiliation(s)
- Thomas Raphael Meinel
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Johannes Kaesmacher
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Pascal John Mosimann
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - David Seiffge
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Simon Jung
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Pasquale Mordasini
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Marcel Arnold
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Martina Goeldlin
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Steven D Hajdu
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Marta Olivé-Gadea
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Christian Maegerlein
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Vincent Costalat
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Laurent Pierot
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Joanna D Schaafsma
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Urs Fischer
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada.
| | - Jan Gralla
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
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García-Tornel Á, Rubiera M, Requena M, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Boned S, Olivé-Gadea M, Tomasello A, Piñana C, Hernández D, Molina CA, Ribo M. Sudden Recanalization: A Game-Changing Factor in Endovascular Treatment of Large Vessel Occlusion Strokes. Stroke 2020; 51:1313-1316. [PMID: 32078495 DOI: 10.1161/strokeaha.119.028787] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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- First pass (FP) recanalization has been shown to be a predictor of favorable outcome in endovascular treatment of stroke. The reasons why FP recanalization leads to better outcome as compared with multiple passes (MP) are unknown. We aim to investigate the recanalization pattern and its relationship with outcome. Methods- Six hundred nine consecutive patients underwent endovascular treatment. Recanalization was defined as modified Thrombolysis in Cerebral Infarction score 2B-3. Favorable outcome was defined as modified Rankin Scale score of 0 to 2 at 90 days. Sudden recanalization (SR) was considered when modified Thrombolysis in Cerebral Infarction score varied from 0-1 to 2B-3 in a single pass. Progressive recanalization (PR) was considered if modified Thrombolysis in Cerebral Infarction score 2A was achieved at an interim pass before achieving recanalization. Patients were also categorized as recanalizers at FP, MP, or nonrecanalizers. Results- Five hundred nine (83.9%) patients achieved recanalization. SR was achieved in 378 (62.1%) patients; 280 (46%) were FP-SR, and 98 (16.1%) were MP-SR. MP-PR was achieved in 131 (21.5%) patients. Rates of favorable outcome were similar between patients with FP-SR (57.5%) and MP-SR (57.1%; odds ratio [OR], 0.9 [CI, 0.53-1.54]; P=0.7) but lower in MP-PR (29.8%; OR, 3.33 [CI, 1.71-5.63]; P<0.01). Patients with MP-PR had better outcome than nonrecanalizer (17%; OR, 2.93 [CI, 1.42-6.15]; P<0.01). In univariate analysis, both FP recanalization (OR, 1.91 [CI, 1.31-2.72]; P<0.01) and SR (OR, 3.19 [CI, 2.12-4.95]; P<0.01) were associated with favorable outcome. However multivariate analysis adjusting for FP recanalization showed that the only procedural predictor of favorable outcome was SR (OR, 3.12 [CI, 1.91-5.16]; P<0.01). Higher number of passes were associated with worse outcome in patients with recanalization (OR, 0.75 [CI, 0.66-0.85]; P<0.01) but not in those with SR (OR, 0.94 [CI, 0.59-1.61]; P=0.937). Conclusions- SR strongly predicts favorable outcome in patients undergoing endovascular treatment, even after previous unsuccessful attempts. PR may reflect clot fragmentation and embolization due to more friable composition, leading to worse outcomes. Prospective studies with independent assessment of recanalization pattern should validate these results.
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Affiliation(s)
- Álvaro García-Tornel
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Marta Rubiera
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Manuel Requena
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Marian Muchada
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Jorge Pagola
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - David Rodriguez-Luna
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Matias Deck
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Jesus Juega
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Sandra Boned
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Marta Olivé-Gadea
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Alejandro Tomasello
- Department of Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.T., C.P., D.H.), Universitat Autònoma de Barcelona, Spain
| | - Carlos Piñana
- Department of Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.T., C.P., D.H.), Universitat Autònoma de Barcelona, Spain
| | - David Hernández
- Department of Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.T., C.P., D.H.), Universitat Autònoma de Barcelona, Spain
| | - Carlos A Molina
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
| | - Marc Ribo
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Barcelona, Spain.,Departament de Medicina (A.G.-T., M. Rubiera, M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Universitat Autònoma de Barcelona, Spain
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Olivé-Gadea M, Requena M, Garcia-Tornel Á, Deck M, Muchada M, Boned S, Rodríguez N, Juega J, Rodríguez-Luna D, Pagola J, Rubiera M, Molina C, Ribó M. Abstract WP104: Defining a Target Population to Effectively Test a Neuroprotective Drug. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp104] [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
We aim to define a target population of stroke patients treated with EVT, in whom a potential neuroprotective (NP) drug has highest chances to show clinical and radiological positive effects.
Methods:
we studied stroke patients treated with EVT. CBF<30% on admission CTP determined infarct core. Final infarct volume (FIV) was measured on 24-48h CT and NIHSS at discharge/day 5 (dNIHSS). We analyzed the clinical impact of absolute (1cc) and relative (30%) NP-mediated FIV reductions in dNIHSS. Segmented linear regressions were used to identify significant breakpoints in FIV/dNIHSS association. Models were adjusted for age, sex and baseline NIHSS.
Results:
We included 211 patients, mean FIV was 39(±58)cc and median dNIHSS 6(1-15). FIV strongly correlated to dNIHSS (rs=0.74; p<0.01). We defined 3 subgroups: minimal (≤1cc), moderate (2-80cc) and large (≥80cc) FIV. A) FIV ≤1 (22.3% of patients): mean FIV was 0.23±0.4cc, median NIHSS was 1(0-3). Neither absolute (1cc) nor 30% relative (-0.07±0.1cc) FIV reduction showed a significant impact in dNIHSS (±0 points). B) FIV 2-80cc (59.7%): mean FIV was 22.9±18.3cc, median dNIHSS was 7(2-13). Per each cc FIV reduction dNIHSS decreased by 0.23 (CI 0.17-0.29) points. A 30% reduction in mean FIV (6.9cc) may lower dNIHSS 1.6 points. C) FIV≥80cc (18%): mean FIV was 143±66cc, median dNIHSS was 19(12-30). Per each cc FIV reduction dNIHSS decreased by 0.07 (CI 0.03-0.12). A 30% reduction in mean FIV (43cc) may reduce dNIHSS 3 points. An infarct core <5cc (Sn 73%, Sp 75%; AUC 0.8, CI 0.74-0.86) predicted FIV ≤1cc. An infarct core≥30cc predicted FIV≥80cc (Sn 71%; Sp 85%; AUC 0.87; CI 0.8-0.93).
Conclusion:
One in 4 patients will develop minimal FIV, including these patients in NP trials may dilute a treatment effect and reduce odds of positive results. In large FIV patients, mild relative clinical impacts may become relevant due to substantial absolute FIV reductions. Admission CTP may help sorting patients according to expected drug effect profile.
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Affiliation(s)
| | - Manuel Requena
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Matías Deck
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | - Marian Muchada
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | - Sandra Boned
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Jesús Juega
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Jorge Pagola
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hosp Universitari Vall d'Hebron, Barcelona, Spain
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28
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Requena M, Olivé-Gadea M, García-Tornel Á, Rodríguez-Villatoro N, Juega J, Deck M, Boned S, Muchada M, Pagola J, Rodríguez-Luna D, Hernández D, Rubiera M, Tomasello A, Molina C, Ribó M. Abstract 146: Time Matters: Adjusted Analysis of the Influence of Direct Transfer to Angio-Suite Protocol in Functional Outcome. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.146] [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
Direct transfer to angio suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The association of different time windows with prognosis in this population is influenced by several factors. We aim to analyze the influence of DTAS in clinical and functional outcome depending on time from symptom onset to treatment.
Methods:
Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to CT (DTCT) from February 2016 to April 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline NIHSS score (±2 points) and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (mRS 0-2) and safety variables stratified in less or more than 3 hours from onset to arrive.
Results:
There were no significant differences regarding age, gender or baseline NIHSS score (table 1). Median door-to-groin time was shorter in the DTAS patients (16 (13-21) minutes Vs 70 (41.5-98.5); p<0.01). DTAS patients presented lower NIHSS score at 24 hours 9 (3.5-17) Vs 14 (5-19); p=0.01) and a lower rate of symptomatic hemorrhagic transformation (4.6% versus 10.9%, p<0.03). At 90 days, DTAS patients had a higher rate of good functional outcome (43% versus 29%; OR 1.81, 95% CI, 1.14-2.87; p=0.01). In multivariate analysis adjusted by confounding factors, better outcome in DTAS was observed in patients admitted in the 0-3 hours form onset window (n=156, OR 2.63, 95%CI: 1.31-5.28; p<0.01), but not in patients admitted in the 3-6 hours window (n=193, OR 1.37 955CI:0.72-2.60, p=0.2).
Conclusion:
DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Marc Ribó
- Vall d'Hebron Hosp, Barcelona, Spain
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29
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Meinel TR, Kniepert JU, Seiffge DJ, Gralla J, Jung S, Auer E, Frey S, Goeldlin M, Mordasini P, Mosimann PJ, Nogueira RG, Haussen DC, Rodrigues GM, Uphaus T, L'Allinec V, Krajíčková D, Alonso A, Costalat V, Hajdu SD, Olivé-Gadea M, Maegerlein C, Pierot L, Schaafsma J, Suzuki K, Arnold M, Heldner MR, Fischer U, Kaesmacher J. Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients. Stroke 2020; 51:892-898. [PMID: 31992179 DOI: 10.1161/strokeaha.119.026606] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [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: 12/31/2022]
Abstract
Background and Purpose- We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods- In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results- Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62-82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35-4.84] and 1.64 [95% CI, 1.09-2.47]) as compared with the control group, whereas no association with DOAC intake was observed (aOR, 0.98 [95% CI, 0.29-3.35] and 1.35 [95% CI, 0.72-2.53]). Sensitivity analyses considering only patients within the confirmed therapeutic anticoagulation range did not alter the findings. A study-level meta-analysis incorporating data from 7462 patients (855 VKAs, 318 DOACs, and 6289 controls) from 15 observational cohorts corroborated these observations, yielding an increased rate of sICH in VKA patients (aOR, 1.62 [95% CI, 1.22-2.17]) but not in DOAC patients (aOR, 1.03 [95% CI, 0.60-1.80]). Conclusions- Patients taking VKA have an increased risk of sICH and mortality after mechanical thrombectomy. The lower risk of sICH associated with DOAC may also be noticeable in the acute setting. Improved selection might be advisable in VKA-treated patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064. Systematic Review and Meta-Analysis: CRD42019127464.
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Affiliation(s)
- Thomas R Meinel
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Joachim U Kniepert
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - David J Seiffge
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Simon Jung
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Elias Auer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Sebastién Frey
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Martina Goeldlin
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.).,University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Raul G Nogueira
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Diogo C Haussen
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Gabriel M Rodrigues
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany, on behalf of the ENDOSTROKE Study Group (T.U.)
| | - Vincent L'Allinec
- Neuroradiology Department, Nantes University Hospital, France (V.L.)
| | - Dagmar Krajíčková
- Department of Neurology, Comprehensive Stroke Center, Faculty of Medicine in Hradec Králové, Charles University and University Hospital Hradec Králové, Czech Republic (D.K.)
| | - Angelika Alonso
- Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (A.A.)
| | | | - Steven D Hajdu
- Department of Radiology, CHUV Lausanne, Switzerland (S.D.H.)
| | - Marta Olivé-Gadea
- Department of Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (M.O.-G.)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M.)
| | | | - Joanna Schaafsma
- Division of Neurology, University Health Network, University of Toronto, Canada (J.S.)
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan (K.S.)
| | - Marcel Arnold
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Mirjam R Heldner
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Urs Fischer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.)
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30
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Requena M, Olivé-Gadea M, Boned S, Ramos A, Cardona P, Urra X, Serena J, Silva Y, Purroy F, Ustrell X, Abilleira S, Tomasello A, Perez de la Ossa N, Molina CA, Ribo M, Rubiera M. Clinical and neuroimaging criteria to improve the workflow in transfers for endovascular treatment evaluation. Int J Stroke 2019; 15:988-994. [DOI: 10.1177/1747493019874725] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Transfer protocols from primary to comprehensive stroke centers are crucial for endovascular treatment success. Aim To evaluate clinical and neuroimaging data of transferred patients and their likelihood of presenting a large infarct core at comprehensive stroke center arrival. Methods Retrospective analysis of population-based mandatory prospective registry of acute stroke patients evaluated for endovascular treatment. Consecutive patients evaluated at primary stroke center with suspected large vessel occlusion and PSC-ASPECTS ≥ 6 transferred to a comprehensive stroke center were included. PSC and CSC-ASPECTS, time-metrics, and clinical data were analyzed. Results During 28 months, 1185 endovascular treatment candidates were transferred from PC to comprehensive stroke center in our public stroke network, 477 had an anterior circulation syndrome and available neuroimaging information and were included. Median baseline NIHSS was 13 (8–19). On arrival to comprehensive stroke center, large vessel occlusion was confirmed in 60.2% patients, and 41.2% received endovascular treatment. Median interfacility ASPECTS decay was 1 (0–2) after a median of 150.7 (SD 101) min between both CT-acquisitions. A logistic regression analysis adjusted by age, time from symptoms to PC-CT, and time from PC-CT to CSC-CT showed that only a baseline NIHSS and PSC-ASPECTS independently predicted a CSC-ASPECTS < 6. ROC curves identified baseline NIHSS ≥ 16 and PSC-ASPECTS ≤ 7 as the best cut-off points. The rate of CSC-ASPECTS < 6 increased from 7% to 57% among patients with NIHSS ≥ 16 and PSC-ASPECS ≤ 7. Conclusion After a median transfer time >2 h, only 11.9% showed ASPECTS < 6 at the comprehensive stroke center. Activation of endovascular treatment teams should not require confirming neuroimaging on arrival and repeating neuroimaging at comprehensive stroke center should only be performed in selected cases.
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Affiliation(s)
- Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Sandra Boned
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Anna Ramos
- Stroke Unit, Department of Neurology, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Pere Cardona
- Stroke Unit, Department of Neurology, Bellvitge University Hospital, Barcelona, Spain
| | - Xabier Urra
- Stroke Unit, Department of Neurology, Clinic Hospital, Barcelona, Spain
| | - Joaquín Serena
- Stroke Unit, Department of Neurology, Doctor Josep Trueta University Hospital, Girona, Spain
| | - Yolanda Silva
- Stroke Unit, Department of Neurology, Doctor Josep Trueta University Hospital, Girona, Spain
| | - Francisco Purroy
- Department of Neurology, Arnau de Vilanova Hospital, Lleida, Spain
| | - Xavier Ustrell
- Stroke Unit, Joan XXIII University Hospital, Tarragona, Spain
| | - Sonia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Alejandro Tomasello
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
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García-Tornel Á, Requena M, Rubiera M, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Boned S, Olivé-Gadea M, Tomasello A, Hernández D, Molina CA, Ribo M. When to Stop. Stroke 2019; 50:1781-1788. [PMID: 31177974 DOI: 10.1161/strokeaha.119.025088] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [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- Substantial proportion of patients who achieve successful recanalization of acute ischemic stroke due to large vessel occlusion do not achieve good functional outcome. We aim to analyze the effect of number of thrombectomy device passes and degree of the recanalization (by modified Thrombolysis in Cerebral Infarction) on the clinical and functional outcome. Methods- Five hundred forty-two consecutive patients underwent mechanical thrombectomy for large vessel occlusion in the anterior circulation at a single tertiary stroke center. Baseline characteristics, number of passes, recanalization degree, clinical outcome at 24 hours (measured by National Institutes of Health Scale score), and functional outcome (measured by modified Rankin Scale at 90 days) were registered. Multivariate analysis was performed to determine the association of number of passes and degree of recanalization with dramatical clinical recovery (final National Institutes of Health Scale score ≤2 or decrease in 8 or more National Institutes of Health Scale score points in 24 hours) and good functional outcome (modified Rankin Scale score ≤2 at 90 days). Results- Four hundred fifty-nine patients (84%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction 2B-3), 213 (39%) of them after first device pass. In the multivariate analysis, first-pass recanalization and modified Thrombolysis in Cerebral Infarction 3 were independent predictors of good functional outcome (odds ratio, 2.5; 95% CI, 1.4-4.5; P=0.002 and odds ratio, 2.6 CI; 1.5-4.7; P=0.001, respectively) and dramatical clinical recovery (odds ratio, 1.8; 95% CI, 1.1-3; P=0.032 and odds ratio, 2.9; 95% CI, 1.7-5.1; P<0.001, respectively). Rate of recanalization declined after each pass 39% (213/542), 35% (113/310), 33% (63/190), and 24% (26/154) for passes 1 to 4, respectively and 28% (45/158) for every attempt above 4 passes ( P<0.001). In patients who achieved recanalization, a linear association between number of passes and good functional outcome was observed: 1 pass (58.6%), 2 passes (50.5%), 3 passes (48.4%), 4 passes (38.5%), or 5 or more passes (25.6%; P<0.001) as compared with patients who did not achieve recanalization (16.9%). Conclusions- High number of device passes and less degree of recanalization are associated with worse outcome in patients with acute ischemic stroke secondary to large vessel occlusion. Future studies should investigate the optimal number of passes that should be attempted in patients without substantial recanalization.
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Affiliation(s)
- Álvaro García-Tornel
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Manuel Requena
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Marta Rubiera
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Marian Muchada
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Jorge Pagola
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - David Rodriguez-Luna
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Matias Deck
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Jesus Juega
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Sandra Boned
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Marta Olivé-Gadea
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Alejandro Tomasello
- Department of Neurorradiology (A.T., D.H.), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - David Hernández
- Department of Neurorradiology (A.T., D.H.), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Carlos A Molina
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Marc Ribo
- From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
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Villanueva V, López-González FJ, Mauri JA, Rodriguez-Uranga J, Olivé-Gadea M, Montoya J, Ruiz-Giménez J, Zurita J. BRIVA-LIFE-A multicenter retrospective study of the long-term use of brivaracetam in clinical practice. Acta Neurol Scand 2019; 139:360-368. [PMID: 30506559 DOI: 10.1111/ane.13059] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Evaluate long-term effectiveness and tolerability of brivaracetam in clinical practice in patients with focal epilepsy. MATERIALS AND METHODS This was a multicenter retrospective study. Patients aged ≥16 years were started on brivaracetam from November 2016 to June 2017 and followed over 1 year. Data were obtained from medical records at 3, 6 and 12 months after treatment initiation for evaluation of safety- and seizure-related outcomes. RESULTS A total of 575 patients were included in analyses; most had been treated with ≥4 lifetime antiepileptic drugs. Target dosage was achieved by 30.6% of patients on the first day. Analysis of primary variables at 12 months revealed that mean reduction in seizure frequency was 36.0%, 39.7% of patients were ≥50% responders and 17.5% were seizure-free. Seizure-freedom was achieved by 37.5% of patients aged ≥65 years. Incidence of adverse events (AEs) and psychiatric AEs (PAEs) was 39.8% and 14.3%, respectively, and discontinuation due to these was 8.9% and 3.7%, respectively. Somnolence, irritability, and dizziness were the most frequently reported AEs. At baseline, 228 (39.7%) patients were being treated with levetiracetam; most switched to brivaracetam (dose ratio 1:10-15). Among those who switched because of PAEs (n = 53), 9 (17%) reported PAEs on brivaracetam, and 3 (5.7%) discontinued because of PAEs. Tolerability was not highly affected among patients with learning disability or psychiatric comorbidity. CONCLUSIONS In a large population of patients with predominantly drug-resistant epilepsy, brivaracetam was effective and well-tolerated; no unexpected AEs occurred over 1 year, and the incidence of PAEs was lower compared with levetiracetam.
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Olivé-Gadea M, Requena M, Fonseca Hernández E, Quintana M, Santamarina E, Abraira Del Fresno L, Álvarez-Sabín J, Salas-Puig X, Toledo M. Etiology, seizure type, and prognosis of epileptic seizures in the emergency department. Epilepsy Behav 2019; 92:327-331. [PMID: 30763767 DOI: 10.1016/j.yebeh.2018.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 09/19/2018] [Revised: 11/25/2018] [Accepted: 12/09/2018] [Indexed: 11/28/2022]
Abstract
UNLABELLED Epileptic seizures are a common reason for emergency department (ED) admittance. We aimed to describe the etiological distribution of epileptic seizures and the relationships between etiology and semiology in patients admitted to the emergency room, and to identify early prognostic factors for recurrence and mortality. METHODS A retrospective observational study was conducted in adult patients consecutively attended in the emergency room with epileptic seizures over a 2-year period. We recorded data on the etiological and syndromic classification of the seizure, and on recurrence and mortality at 1 year of follow-up. RESULTS In total, 289 patients were included. Mean age was 55.9 (±21.9 years). There were 38.6% with a previous diagnosis of epilepsy and 49.8% with new-onset seizures. Among structural epilepsies, a vascular etiology was the most common overall (28.3%) but particularly in elderly (>65 years) patients (50.9%), followed by brain tumors (15.5%). In both etiologies, most patients presented with nonconvulsive seizures. Seizure recurrence during follow-up was reported in 37.1% and was most common in patients with symptomatic remote seizures (50 patients, 41%). Brain tumors (odds ratio (OR): 5.1, confidence interval (CI): 1.7-11.8; p < 0.01), younger age (OR: 0.9, CI: 0.97-0.99; p < 0.05), and a previous diagnosis of epilepsy (OR: 3.5, CI: 1.9-6.3; p < 0.01) were independent predictors of recurrence. Overall mortality was 8.6%. Symptomatic epilepsy was an independent predictor of mortality (hazard ratio (HR): 6.3, CI 1.4-23.4; p < 0.05). CONCLUSIONS The most common etiologies of seizures in patients admitted to the ED are seizures of unknown cause and vascular disorder-related seizures. Seizures are more likely to recur in younger patients with a tumor whereas symptomatic epilepsy is associated with a higher risk of death at a 1-year follow-up.
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Affiliation(s)
- Marta Olivé-Gadea
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain
| | - Manuel Requena
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain
| | - Elena Fonseca Hernández
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain
| | - Laura Abraira Del Fresno
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain
| | - Jose Álvarez-Sabín
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain
| | - Xavier Salas-Puig
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Passeig Vall d'Hebron 119-121, 08035 Barcelona, Spain.
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