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Chen M, Joshi KC, Kolb B, Sitton CW, Pujara DK, Abraham MG, Ortega-Gutierrez S, Kasner SE, Hussain SM, Churilov L, Blackburn S, Sundararajan S, Hu YC, Herial N, Arenillas JF, Tsai JP, Budzik RF, Hicks W, Kozak O, Yan B, Cordato D, Manning NW, Parsons M, Hanel RA, Aghaebrahim A, Wu T, Cardona Portela P, Gandhi CD, Al-Mufti F, Perez de la Ossa N, Schaafsma J, Blasco J, Sangha N, Warach S, Kleinig TJ, Johns H, Shaker F, Abdulrazzak MA, Ray A, Sunshine J, Opaskar A, Duncan KR, Xiong W, Al-Shaibi FK, Samaniego EA, Nguyen TN, Fifi JT, Tjoumakaris SI, Jabbour P, Mendes Pereira V, Lansberg MG, Sila C, Bambakidis NC, Davis S, Wechsler L, Albers GW, Grotta JC, Ribo M, Hassan AE, Campbell B, Hill MD, Sarraj A. Clinical relevance of intracranial hemorrhage after thrombectomy versus medical management for large core infarct: a secondary analysis of the SELECT2 randomized trial. J Neurointerv Surg 2024:jnis-2023-021219. [PMID: 38471760 DOI: 10.1136/jnis-2023-021219] [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: 11/02/2023] [Accepted: 02/18/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The incidence of intracerebral hemorrhage (ICH) and its effect on the outcomes after endovascular thrombectomy (EVT) for patients with large core infarcts have not been well-characterized. METHODS SELECT2 trial follow-up imaging was evaluated using the Heidelberg Bleeding Classification (HBC) to define hemorrhage grade. The association of ICH with clinical outcomes and treatment effect was examined. RESULTS Of 351 included patients, 194 (55%) and 189 (54%) demonstrated intracranial and intracerebral hemorrhage, respectively, with a higher incidence in EVT (134 (75%) and 130 (73%)) versus medical management (MM) (60 (35%) and 59 (34%), both P<0.001). Hemorrhagic infarction type 1 (HBC=1a) and type 2 (HBC=1b) accounted for 93% of all hemorrhages. Parenchymal hematoma (PH) type 1 (HBC=1c) and type 2 (HBC=2) were observed in 1 (0.6%) EVT-treated and 4 (2.2%) MM patients. Symptomatic ICH (sICH) (SITS-MOST definition) was seen in 0.6% EVT patients and 1.2% MM patients. No trend for ICH with core volumes (P=0.10) or Alberta Stroke Program Early CT Score (ASPECTS) (P=0.74) was observed. Among EVT patients, the presence of any ICH did not worsen clinical outcome (modified Rankin Scale (mRS) at 90 days: 4 (3-6) vs 4 (3-6); adjusted generalized OR 1.00, 95% CI 0.68 to 1.47, P>0.99) or modify EVT treatment effect (Pinteraction=0.77). CONCLUSIONS ICH was present in 75% of the EVT population, but PH or sICH were infrequent. The presence of any ICH did not worsen functional outcomes or modify EVT treatment effect at 90-day follow-up. The high rate of hemorrhages overall still represents an opportunity for adjunctive therapies in EVT patients with a large ischemic core.
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Affiliation(s)
- Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Krishna C Joshi
- Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Bradley Kolb
- Rush University Medical Center, Chicago, Illinois, USA
| | - Clark W Sitton
- Diagnostic & Interventional Imaging, UT Houston, Houston, Texas, USA
| | | | - Michael G Abraham
- Neurology and Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Santiago Ortega-Gutierrez
- Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott E Kasner
- Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shazam M Hussain
- Cleveland Clinic Stroke Program, Cleveland Clinic, Cleveland Heights, Ohio, USA
| | | | - Spiros Blackburn
- Neurosurgery, University of Texas Medical School at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA
| | | | - Yin C Hu
- Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Nabeel Herial
- Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Juan F Arenillas
- Stroke Unit, Neurology Department, Stroke Unit. Neurology Department. Universitary Hospital, Valladolid (Spain), Valladolid, Spain
| | - Jenny P Tsai
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - William Hicks
- OhioHealth Neurological Physicians, Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Osman Kozak
- Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Abington Memorial Hospital, Abington, Pennsylvania, USA
| | - Bernard Yan
- The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Nathan W Manning
- Institute of Neurosciences, UNSW Prince of Wales Clinical School, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Mark Parsons
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | | | - Amin Aghaebrahim
- Neurological Institute, Lyerley Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Teddy Wu
- Neurology, Christchurch Hospital, Christchurch, Canterbury, New Zealand
| | | | - Chirag D Gandhi
- Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | | | - Joanna Schaafsma
- Medicine - Div. Neurology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jordi Blasco
- Neurointerventional Department C.D.I, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Navdeep Sangha
- Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Steven Warach
- University of Texas at Austin Dell Seton Medical Center, Austin, Texas, USA
| | - Timothy J Kleinig
- Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hannah Johns
- University of Melbourne, Parkville, Victoria, Australia
| | - Faris Shaker
- Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | - Abhishek Ray
- Neurological Surgery, University Hospitals, Cleveland, Ohio, USA
| | - Jeffery Sunshine
- Radiology, University Hospitals-Case Medical Center, Cleveland, Ohio, USA
| | - Amanda Opaskar
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Kelsey R Duncan
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Wei Xiong
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Edgar A Samaniego
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Maarten G Lansberg
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Cathy Sila
- Neurological Institute, University Hospitals- Case Medical Center, Cleveland, Ohio, USA
- Neurology, Case Western Reserve University School of Medicine
| | - Nicholas C Bambakidis
- Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Stephen Davis
- The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lawrence Wechsler
- University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Gregory W Albers
- Neurology & Neurological Sciences, Stanford University, Stanford, California, USA
| | - James C Grotta
- Neurology, Memorial Hermann Hospital/UT Houston, Houston, Texas, USA
| | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Bruce Campbell
- The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Amrou Sarraj
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Sarraj A, Hassan AE, Abraham MG, Ortega-Gutierrez S, Kasner SE, Hussain MS, Chen M, Churilov L, Johns H, Sitton CW, Yogendrakumar V, Ng FC, Pujara DK, Blackburn S, Sundararajan S, Hu YC, Herial NA, Arenillas JF, Tsai JP, Budzik RF, Hicks WJ, Kozak O, Yan B, Cordato DJ, Manning NW, Parsons MW, Cheung A, Hanel RA, Aghaebrahim AN, Wu TY, Portela PC, Gandhi CD, Al-Mufti F, Pérez de la Ossa N, Schaafsma JD, Blasco J, Sangha N, Warach S, Kleinig TJ, Shaker F, Al Shaibi F, Toth G, Abdulrazzak MA, Sharma G, Ray A, Sunshine J, Opaskar A, Duncan KR, Xiong W, Samaniego EA, Maali L, Lechtenberg CG, Renú A, Vora N, Nguyen T, Fifi JT, Tjoumakaris SI, Jabbour P, Tsivgoulis G, Pereira VM, Lansberg MG, DeGeorgia M, Sila CA, Bambakidis N, Hill MD, Davis SM, Wechsler L, Grotta JC, Ribo M, Albers GW, Campbell BC. Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles. JAMA 2024; 331:750-763. [PMID: 38324414 PMCID: PMC10851143 DOI: 10.1001/jama.2024.0572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
Importance Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain. Objective To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect. Design, Setting, and Participants An exploratory analysis of the SELECT2 trial, which randomized 352 adults (18-85 years) with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) and large ischemic core to EVT vs medical management (MM), across 31 global centers between October 2019 and September 2022. Intervention EVT vs MM. Main Outcomes and Measures Primary outcome was functional outcome-90-day mRS score (0, no symptoms, to 6, death) assessed by adjusted generalized OR (aGenOR; values >1 represent more favorable outcomes). Benefit of EVT vs MM was assessed across levels of ischemic injury defined by noncontrast CT using ASPECTS score and by the volume of brain with severely reduced blood flow on CT perfusion or restricted diffusion on MRI. Results Among 352 patients randomized, 336 were analyzed (median age, 67 years; 139 [41.4%] female); of these, 168 (50%) were randomized to EVT, and 2 additional crossover MM patients received EVT. In an ordinal analysis of mRS at 90 days, EVT improved functional outcomes compared with MM within ASPECTS categories of 3 (aGenOR, 1.71 [95% CI, 1.04-2.81]), 4 (aGenOR, 2.01 [95% CI, 1.19-3.40]), and 5 (aGenOR, 1.85 [95% CI, 1.22-2.79]). Across strata for CT perfusion/MRI ischemic core volumes, aGenOR for EVT vs MM was 1.63 (95% CI, 1.23-2.16) for volumes ≥70 mL, 1.41 (95% CI, 0.99-2.02) for ≥100 mL, and 1.47 (95% CI, 0.84-2.56) for ≥150 mL. In the EVT group, outcomes worsened as ASPECTS decreased (aGenOR, 0.91 [95% CI, 0.82-1.00] per 1-point decrease) and as CT perfusion/MRI ischemic core volume increased (aGenOR, 0.92 [95% CI, 0.89-0.95] per 10-mL increase). No heterogeneity of EVT treatment effect was observed with or without mismatch, although few patients without mismatch were enrolled. Conclusion and Relevance In this exploratory analysis of a randomized clinical trial of patients with extensive ischemic stroke, EVT improved clinical outcomes across a wide spectrum of infarct volumes, although enrollment of patients with minimal penumbra volume was low. In EVT-treated patients, clinical outcomes worsened as presenting ischemic injury estimates increased. Trial Registration ClinicalTrials.gov Identifier: NCT03876457.
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Affiliation(s)
- Amrou Sarraj
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | - Michael Chen
- Rush University Medical Center, Chicago, Illinois
| | - Leonid Churilov
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Hannah Johns
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | | | - Vignan Yogendrakumar
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Felix C. Ng
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Deep K. Pujara
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | - Sophia Sundararajan
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Yin C. Hu
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Nabeel A. Herial
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Juan F. Arenillas
- Hospital Clínico Universitario Valladolid—University of Valladolid, Valladolid, Spain
| | | | | | | | - Osman Kozak
- Abington Jefferson Health, Abington, Pennsylvania
| | - Bernard Yan
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | | | | | | | - Andrew Cheung
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | | | | | - Teddy Y. Wu
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | - Fawaz Al-Mufti
- Westchester Medical Center, New York Medical College, Valhalla
| | | | | | | | | | - Steven Warach
- Dell Medical School at The University of Texas at Austin–Ascension Texas, Austin
| | | | - Faris Shaker
- McGovern Medical School at UTHealth, Houston, Texas
| | - Faisal Al Shaibi
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | | | - Gagan Sharma
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Abhishek Ray
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Jeffrey Sunshine
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Amanda Opaskar
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Kelsey R. Duncan
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Wei Xiong
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | - Laith Maali
- University of Kansas Medical Center, Kansas City
| | | | - Arturo Renú
- Hospital Clínic de Barcelona, Barcelona, Spain
| | - Nirav Vora
- Riverside Methodist Hospital, OhioHealth, Columbus
| | | | | | | | - Pascal Jabbour
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Georgios Tsivgoulis
- Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Michael DeGeorgia
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Cathy A. Sila
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Nicholas Bambakidis
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | - Stephen M. Davis
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Marc Ribo
- Hospital Vall d’Hebrón, Barcelona, Spain
| | | | - Bruce C. Campbell
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
- Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia
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3
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Sarraj A, Abraham MG, Hassan AE, Blackburn S, Kasner SE, Ortega-Gutierrez S, Hussain MS, Chen M, Johns H, Churilov L, Pujara DK, Shaker F, Maali L, Cardona Portela P, Herial NA, Gibson D, Kozak O, Arenillas JF, Yan B, Pérez de la Ossa N, Sundararajan S, Hu YC, Cordato DJ, Manning NW, Hanel RA, Aghaebrahim AN, Budzik RF, Hicks WJ, Blasco J, Wu TY, Tsai JP, Schaafsma JD, Gandhi CD, Al-Mufti F, Sangha N, Warach S, Kleinig TJ, Yogendrakumar V, Ng F, Samaniego EA, Abdulrazzak MA, Parsons MW, Rahbar MH, Nguyen TN, Fifi JT, Mendes Pereira V, Lansberg MG, Albers GW, Furlan AJ, Jabbour P, Sitton CW, Sila C, Bambakidis N, Davis SM, Wechsler L, Hill MD, Grotta JC, Ribo M, Campbell BCV. Endovascular thrombectomy plus medical care versus medical care alone for large ischaemic stroke: 1-year outcomes of the SELECT2 trial. Lancet 2024; 403:731-740. [PMID: 38346442 DOI: 10.1016/s0140-6736(24)00050-3] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Multiple randomised trials have shown efficacy and safety of endovascular thrombectomy in patients with large ischaemic stroke. The aim of this study was to evaluate long-term (ie, at 1 year) evidence of benefit of thrombectomy for these patients. METHODS SELECT2 was a phase 3, open-label, international, randomised controlled trial with blinded endpoint assessment, conducted at 31 hospitals in the USA, Canada, Spain, Switzerland, Australia, and New Zealand. Patients aged 18-85 years with ischaemic stroke due to proximal occlusion of the internal carotid artery or of the first segment of the middle cerebral artery, showing large ischaemic core on non-contrast CT (Alberta Stroke Program Early Computed Tomographic Score of 3-5 [range 0-10, with lower values indicating larger infarctions]) or measuring 50 mL or more on CT perfusion and MRI, were randomly assigned, within 24 h of ischaemic stroke onset, to thrombectomy plus medical care or to medical care alone. The primary outcome for this analysis was the ordinal modified Rankin Scale (range 0-6, with higher scores indicating greater disability) at 1-year follow-up in an intention-to-treat population. The trial is registered at ClinicalTrials.gov (NCT03876457) and is completed. FINDINGS The trial was terminated early for efficacy at the 90-day follow-up after 352 patients had been randomly assigned (178 to thrombectomy and 174 to medical care only) between Oct 11, 2019, and Sept 9, 2022. Thrombectomy significantly improved the 1-year modified Rankin Scale score distribution versus medical care alone (Wilcoxon-Mann-Whitney probability of superiority 0·59 [95% CI 0·53-0·64]; p=0·0019; generalised odds ratio 1·43 [95% CI 1·14-1·78]). At the 1-year follow-up, 77 (45%) of 170 patients receiving thrombectomy had died, compared with 83 (52%) of 159 patients receiving medical care only (1-year mortality relative risk 0·89 [95% CI 0·71-1·11]). INTERPRETATION In patients with ischaemic stroke due to a proximal occlusion and large core, thrombectomy plus medical care provided a significant functional outcome benefit compared with medical care alone at 1-year follow-up. FUNDING Stryker Neurovascular.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.
| | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Ameer E Hassan
- Department of Neuroscience, Valley Baptist Medical Center, Harlingen, TX, USA
| | - Spiros Blackburn
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Michael Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Hannah Johns
- Department of Medicine and Neurology, University of Melbourne, Parkville, VC, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, University of Melbourne, Parkville, VC, Australia
| | - Deep K Pujara
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Faris Shaker
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Laith Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Daniel Gibson
- Department of Neurosurgery, Ascension Wisconsin, Indianapolis, IN, USA
| | - Osman Kozak
- Department of Neurosurgery, Abington Jefferson Health, Abington, PA, USA
| | - Juan F Arenillas
- Department of Internal Medicine, Hospital Clínico Universitario Valladolid-University of Valladolid, Valladolid, Spain
| | - Bernard Yan
- Department of Medicine and Neurology, University of Melbourne, Parkville, VC, Australia; Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia
| | | | - Sophia Sundararajan
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Yin C Hu
- Department of Neurosurgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurosurgery, Case Western Reserve University, Cleveland, OH, USA
| | - Dennis J Cordato
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Nathan W Manning
- Department of Neurosurgery, Ingham Institute, Liverpool, NSW, Australia
| | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL, USA
| | - Amin N Aghaebrahim
- Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL, USA
| | - Ronald F Budzik
- Department of Neuro-Interventional Radiology, OhioHealth-Riverside Methodist Hospital, Columbus, OH, USA
| | - William J Hicks
- Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus, OH, USA
| | - Jordi Blasco
- Department of Interventional Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jenny P Tsai
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Joanna D Schaafsma
- Department of Internal Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center-NY Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center-NY Medical College, Valhalla, NY, USA
| | - Navdeep Sangha
- Department of Neurology, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | - Steven Warach
- Department of Neurology, Dell Medical School at The University of Texas at Austin-Ascension Texas, Austin, TX, USA
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Vignan Yogendrakumar
- Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia
| | - Felix Ng
- Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia
| | - Edgar A Samaniego
- Department of Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Mohammad H Rahbar
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Johanna T Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | | | | | - Greg W Albers
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Anthony J Furlan
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Clark W Sitton
- Department of Interventional and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Cathy Sila
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Nicholas Bambakidis
- Department of Neurosurgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurosurgery, Case Western Reserve University, Cleveland, OH, USA
| | - Stephen M Davis
- Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia
| | - Lawrence Wechsler
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael D Hill
- Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada
| | - James C Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Houston, TX, USA
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Bruce C V Campbell
- Department of Medicine and Neurology, University of Melbourne, Parkville, VC, Australia; Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia; Department of Medicine and Neurology, The Florey Institute for Neuroscience and Mental Health, Parkville, VC, Australia
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4
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Sarraj A, Hill MD, Hussain MS, Abraham MG, Ortega-Gutierrez S, Chen M, Kasner SE, Churilov L, Pujara DK, Johns H, Blackburn S, Sundararajan S, Hu YC, Herial NA, Budzik RF, Hicks WJ, Arenillas JF, Tsai JP, Kozak O, Cordato DJ, Hanel RA, Wu TY, Portela PC, Gandhi CD, Al-Mufti F, Maali L, Gibson D, Pérez de la Ossa N, Schaafsma JD, Blasco J, Sangha N, Warach S, Kleinig TJ, Shaker F, Sitton CW, Nguyen T, Fifi JT, Jabbour P, Furlan A, Lansberg MG, Tsivgoulis G, Sila C, Bambakidis N, Davis S, Wechsler L, Albers GW, Grotta JC, Ribo M, Campbell BC, Hassan AE. Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes: A Prespecified Analysis of the SELECT2 Trial. JAMA Neurol 2024:2815043. [PMID: 38363872 PMCID: PMC10853865 DOI: 10.1001/jamaneurol.2024.0206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/11/2024] [Indexed: 02/18/2024]
Abstract
Importance Patients with large ischemic core stroke have poor clinical outcomes and are frequently not considered for interfacility transfer for endovascular thrombectomy (EVT). Objective To assess EVT treatment effects in transferred vs directly presenting patients and to evaluate the association between transfer times and neuroimaging changes with EVT clinical outcomes. Design, Setting, and Participants This prespecified secondary analysis of the SELECT2 trial, which evaluated EVT vs medical management (MM) in patients with large ischemic stroke, evaluated adults aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) as well as an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5, core of 50 mL or greater on imaging, or both. Patients were enrolled between October 2019 and September 2022 from 31 EVT-capable centers in the US, Canada, Europe, Australia, and New Zealand. Data were analyzed from August 2023 to January 2024. Interventions EVT vs MM. Main Outcomes and Measures Functional outcome, defined as modified Rankin Scale (mRS) score at 90 days with blinded adjudication. Results A total of 958 patients were screened and 606 patients were excluded. Of 352 enrolled patients, 145 (41.2%) were female, and the median (IQR) age was 66.5 (58-75) years. A total of 211 patients (59.9%) were transfers, while 141 (40.1%) presented directly. The median (IQR) transfer time was 178 (136-230) minutes. The median (IQR) ASPECTS decreased from the referring hospital (5 [4-7]) to an EVT-capable center (4 [3-5]). Thrombectomy treatment effect was observed in both directly presenting patients (adjusted generalized odds ratio [OR], 2.01; 95% CI, 1.42-2.86) and transferred patients (adjusted generalized OR, 1.50; 95% CI, 1.11-2.03) without heterogeneity (P for interaction = .14). Treatment effect point estimates favored EVT among 82 transferred patients with a referral hospital ASPECTS of 5 or less (44 received EVT; adjusted generalized OR, 1.52; 95% CI, 0.89-2.58). ASPECTS loss was associated with numerically worse EVT outcomes (adjusted generalized OR per 1-ASPECTS point loss, 0.89; 95% CI, 0.77-1.02). EVT treatment effect estimates were lower in patients with transfer times of 3 hours or more (adjusted generalized OR, 1.15; 95% CI, 0.73-1.80). Conclusions and Relevance Both directly presenting and transferred patients with large ischemic stroke in the SELECT2 trial benefited from EVT, including those with low ASPECTS at referring hospitals. However, the association of EVT with better functional outcomes was numerically better in patients presenting directly to EVT-capable centers. Prolonged transfer times and evolution of ischemic change were associated with worse EVT outcomes. These findings emphasize the need for rapid identification of patients suitable for transfer and expedited transport. Trial Registration ClinicalTrials.gov Identifier: NCT03876457.
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Affiliation(s)
- Amrou Sarraj
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Michael D. Hill
- Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada
| | - M. Shazam Hussain
- Cerebrovascular Center, Neurology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Michael Chen
- Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | | | - Leonid Churilov
- Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Deep K. Pujara
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Hannah Johns
- Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Spiros Blackburn
- Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Sophia Sundararajan
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Yin C. Hu
- Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Nabeel A. Herial
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ronald F. Budzik
- Neuro-Interventional Radiology, OhioHealth, Riverside Methodist Hospital, Columbus
| | | | - Juan F. Arenillas
- Internal Medicine, Hospital Clínico Universitario Valladolid, University of Valladolid, Valladolid, Spain
| | | | - Osman Kozak
- Neurosurgery, Abington Jefferson Health, Abington, Pennsylvania
| | | | - Ricardo A. Hanel
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida
| | - Teddy Y. Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Chirag D. Gandhi
- Neurosurgery, Westchester Medical Center, NY Medical College, Valhalla, New York
| | - Fawaz Al-Mufti
- Neurosurgery, Westchester Medical Center, NY Medical College, Valhalla, New York
| | - Laith Maali
- Neurology, University of Kansas Medical Center, Kansas City
| | - Daniel Gibson
- Neurointerventional Surgery, Ascension Columbia St Mary’s Hospital, Milwaukee, Wisconsin
| | | | | | - Jordi Blasco
- Stroke Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Navdeep Sangha
- Neurology, Kaiser Permanente Southern California, Los Angeles
| | - Steven Warach
- Neurology, Dell Medical School at The University of Texas at Austin, Ascension Texas, Austin
| | | | - Faris Shaker
- Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Clark W. Sitton
- Interventioal and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, Texas
| | - Thanh Nguyen
- Neurology, Boston Medical Center, Boston, Massachusetts
| | - Johanna T. Fifi
- Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Anthony Furlan
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Cathy Sila
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Nicholas Bambakidis
- Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Stephen Davis
- Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | | | | | - James C. Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Houston, Texas
| | - Marc Ribo
- Neurology, Hospital Vall d’Hebrón, Sabadell, Spain
| | - Bruce C. Campbell
- Medicine and Neurology, The Royal Melbourne Hospital, The Florey Institute for Neuroscience and Mental Health, Melbourne, Australia
| | - Ameer E. Hassan
- Neuroscience, Valley Baptist Medical Center, Harlingen, Texas
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Hernández-Jiménez M, Abad-Santos F, Cotgreave I, Gallego J, Jilma B, Flores A, Jovin TG, Vivancos J, Hernández-Pérez M, Molina CA, Montaner J, Casariego J, Dalsgaard M, Liebeskind DS, Cobo E, Castellanos M, Portela PC, Masjuán J, Moniche F, Tembl JI, Terceño Izaga M, Arenillas JF, Callejas P, Olivot JM, Calviere L, Henon H, Mazighi M, Piñeiro D, Pugliese M, González VM, Moro MA, Garcia-Tornel A, Lizasoain I, Ribo M. Safety and Efficacy of ApTOLL in Patients With Ischemic Stroke Undergoing Endovascular Treatment: A Phase 1/2 Randomized Clinical Trial. JAMA Neurol 2023; 80:779-788. [PMID: 37338893 PMCID: PMC10282959 DOI: 10.1001/jamaneurol.2023.1660] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 01/05/2023] [Accepted: 03/17/2023] [Indexed: 06/21/2023]
Abstract
Importance ApTOLL is a TLR4 antagonist with proven preclinical neuroprotective effect and a safe profile in healthy volunteers. Objective To assess the safety and efficacy of ApTOLL in combination with endovascular treatment (EVT) for patients with ischemic stroke. Design, Setting, and Participants This phase 1b/2a, double-blind, randomized, placebo-controlled study was conducted at 15 sites in Spain and France from 2020 to 2022. Participants included patients aged 18 to 90 years who had ischemic stroke due to large vessel occlusion and were seen within 6 hours after stroke onset; other criteria were an Alberta Stroke Program Early CT Score of 6 to 10, estimated infarct core volume on baseline computed tomography perfusion of 5 to 70 mL, and the intention to undergo EVT. During the study period, 4174 patients underwent EVT. Interventions In phase 1b, 0.025, 0.05, 0.1, or 0.2 mg/kg of ApTOLL or placebo; in phase 2a, 0.05 or 0.2 mg/kg of ApTOLL or placebo; and in both phases, treatment with EVT and intravenous thrombolysis if indicated. Main Outcomes and Measures The primary end point was the safety of ApTOLL based on death, symptomatic intracranial hemorrhage (sICH), malignant stroke, and recurrent stroke. Secondary efficacy end points included final infarct volume (via MRI at 72 hours), NIHSS score at 72 hours, and disability at 90 days (modified Rankin Scale [mRS] score). Results In phase Ib, 32 patients were allocated evenly to the 4 dose groups. After phase 1b was completed with no safety concerns, 2 doses were selected for phase 2a; these 119 patients were randomized to receive ApTOLL, 0.05 mg/kg (n = 36); ApTOLL, 0.2 mg/kg (n = 36), or placebo (n = 47) in a 1:1:√2 ratio. The pooled population of 139 patients had a mean (SD) age of 70 (12) years, 81 patients (58%) were male, and 58 (42%) were female. The primary end point occurred in 16 of 55 patients (29%) receiving placebo (10 deaths [18.2%], 4 sICH [7.3%], 4 malignant strokes [7.3%], and 2 recurrent strokes [3.6%]); in 15 of 42 patients (36%) receiving ApTOLL, 0.05 mg/kg (11 deaths [26.2%], 3 sICH [7.2%], 2 malignant strokes [4.8%], and 2 recurrent strokes [4.8%]); and in 6 of 42 patients (14%) receiving ApTOLL, 0.2 mg/kg (2 deaths [4.8%], 2 sICH [4.8%], and 3 recurrent strokes [7.1%]). ApTOLL, 0.2 mg/kg, was associated with lower NIHSS score at 72 hours (mean difference log-transformed vs placebo, -45%; 95% CI, -67% to -10%), smaller final infarct volume (mean difference log-transformed vs placebo, -42%; 95% CI, -66% to 1%), and lower degrees of disability at 90 days (common odds ratio for a better outcome vs placebo, 2.44; 95% CI, 1.76 to 5.00). Conclusions and Relevance In acute ischemic stroke, 0.2 mg/kg of ApTOLL administered within 6 hours of onset in combination with EVT was safe and associated with a potential meaningful clinical effect, reducing mortality and disability at 90 days compared with placebo. These preliminary findings await confirmation from larger pivotal trials. Trial Registration ClinicalTrials.gov Identifier: NCT04734548.
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Affiliation(s)
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Ian Cotgreave
- Department of Chemical and Pharmaceutical Safety, Division of Bioeconomy and Health, Research Institutes of Sweden, Södertälje, Sweden
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Alan Flores
- Stroke Unit, Hospital Joan XXIII, Tarragona, Spain
| | | | - José Vivancos
- Stroke Unit, Department of Neurology, Hospital La Princesa, Madrid, Spain
| | - María Hernández-Pérez
- Stroke Unit, Department of Neuroscience Hospital Germans Trias I Pujol, Barcelona, Spain
| | - Carlos A. Molina
- Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Joan Montaner
- Department of Neurology, Hospital Macarena, Sevilla, Spain
| | | | | | - David S. Liebeskind
- Neurovascular Imaging Research Core, Department of Neurology, UCLA Stroke Center, Los Angeles, California
| | - Erik Cobo
- Statistics and Operations Research, Barcelona-Tech, Barcelona, Spain
| | - Mar Castellanos
- Department of Neurology, Complejo Hospitalario Universitario/Biomedical Research Institute, A Coruña, Spain
| | | | - Jaime Masjuán
- Stroke Unit, Department of Neurology, Ramón y Cajal University Hospital, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Francisco Moniche
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Seville, Spain
| | | | - Mikel Terceño Izaga
- Stroke Unit, Department of Neurology, Institut d’Investigació Biomèdica de Girona, Hospital Doctor Josep Trueta de Girona, Spain
| | | | - Patricia Callejas
- Department of Neurology and Stroke Center, University Hospital 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain
| | - Jean Marc Olivot
- Department of Vascular Neurology and Clinical Investigating Center 1435, Toulouse University Hospital, France
| | - Lionel Calviere
- Department of Vascular Neurology and Clinical Investigating Center 1435, Toulouse University Hospital, France
| | - Hilde Henon
- University Lille, Inserm, CHU Lille, U1172, Lille Neuroscience and Cognition, Lille, France
| | - Mikael Mazighi
- Université Paris Cité, INSERM 1148, Department of Neurology, Hopital Lariboisière-APHP Nord, and Interventional Neuroradiology, Hopital Fondation Adolphe Rothschild, FHU Neurovasc, Paris, France
| | | | | | - Victor M. González
- Aptus Biotech, Madrid, Spain
- Grupo de Aptámeros, Departamento de Bioquímica-Investigación, Instituto Ramón y Cajal de Investigación Sanitaria, Ramón y Cajal University Hospital, Madrid, Spain
| | - Maria Angeles Moro
- Unidad de Investigación Neurovascular, Department of Pharmacology and Toxicology, Faculty of Medicine, Universidad Complutense, Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain
| | | | - Ignacio Lizasoain
- Unidad de Investigación Neurovascular, Department of Pharmacology and Toxicology, Faculty of Medicine, Universidad Complutense, Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain
| | - Marc Ribo
- aptaTargets, Madrid, Spain
- Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
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6
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Solà Muñoz S, Escudero Campillo MDM, Soro Borrega C, Azeli Y, Querol Gil S, Ruiz A, Albacete G, Moreno Peral O, Lluch S, Amaro Delgado S, Silva Blas Y, Urra X, Cocho Calderón D, Martí Fàbregas J, Ribó Jacobi M, Cardona Portela P, Purroy García F, Duarte Oller E, Hidalgo Benítez V, Flores A, Rubiera M, Palomeras E, García-Tornel Á, Suñer Soler R, Vilar Roquet D, Salvat-Plana M, Ramos Pachón A, Pérez de la Ossa Herrero N, Jiménez Fàbrega X. Prehospital care process and hospital outcomes in stroke-code cases: comparison of basic and advance life support ambulance attendance. Emergencias 2023; 35:167-175. [PMID: 37350599] [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] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
OBJECTIVES To study prehospital care process in relation to hospital outcomes in stroke-code cases first attended by 2 different levels of ambulance. To analyze factors associated with a satisfactory functional outcome at 3 months. MATERIAL AND METHODS Prospective multicenter observational cohort study. All stroke-code cases attended by prehospital emergency services from January 2016 to April 2022 were included. Prehospital and hospital variables were collected. The classificatory variable was type of ambulance attending (basic vs advanced life support). The main outcome variables were mortality and functional status after ischemic strokes in patients who underwent reperfusion treatment 90 days after the ischemic episode. RESULTS Out of 22 968 stroke-code activations, ischemic stroke was diagnosed in 12 467 patients (54.3%) whose functional status was good before the episode. Basic ambulances attended 93.1%; an advanced ambulance was ordered in 1.6% of the patients. Even though there were differences in patient and clinical characteristics recorded during the prehospital process, type of ambulance was not independently associated with mortality (adjusted odds ratio [aOR], 1.1; 95% CI, 0.77-1.59) or functional status at 3 months (aOR, 1.05; 95% CI, 0,72-1,47). CONCLUSION The percentage of patient complications in stroke-code cases attended by basic ambulance teams is low. Type of ambulance responding was not associated with either mortality or functional outcome at 3 months in this study.
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Affiliation(s)
| | | | | | - Youcef Azeli
- Sistema d'Emergències Mèdiques, Barcelona, España
| | | | - Antoni Ruiz
- Sistema d'Emergències Mèdiques, Barcelona, España
| | | | | | - Sergi Lluch
- Sistema d'Emergències Mèdiques, Barcelona, España
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rosa Suñer Soler
- Universitat de Girona. Grup de Recerca Salut i Atenció Sanitària, Girona, España
| | - Daniel Vilar Roquet
- Pla Nacional d'Urgències de Catalunya (PLANUC), Servei Català de la Salut, España
| | - Mercè Salvat-Plana
- Pla Director de la Malaltia Vascular Cerebral. Departament de Salut, Barcelona, España
| | | | | | - Xavier Jiménez Fàbrega
- Sistema d'Emergències Mèdiques, Barcelona, España. Pla Director de la Malaltia Vascular Cerebral. Departament de Salut, Barcelona, España
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Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [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: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
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Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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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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9
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Bonaterra-Pastra A, Benítez S, Pancorbo O, Rodríguez-Luna D, Vert C, Rovira A, Freijo MM, Tur S, Martínez-Zabaleta M, Cardona Portela P, Vera R, Lebrato-Hernández L, Arenillas JF, Pérez-Sánchez S, Domínguez-Mayoral A, Fàbregas JM, Mauri G, Montaner J, Sánchez-Quesada JL, Hernández-Guillamon M. Association of candidate genetic variants and circulating levels of ApoE/ApoJ with common neuroimaging features of cerebral amyloid angiopathy. Front Aging Neurosci 2023; 15:1134399. [PMID: 37113571 PMCID: PMC10126235 DOI: 10.3389/fnagi.2023.1134399] [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: 12/30/2022] [Accepted: 03/27/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction Cerebral amyloid angiopathy (CAA) is characterized by the accumulation of amyloid-β (Aβ) in brain vessels and is a main cause of lobar intracerebral hemorrhage (ICH) in the elderly. CAA is associated with magnetic resonance imaging (MRI) markers of small vessel disease (SVD). Since Aβ is also accumulated in Alzheimer's disease (AD) in the brain parenchyma, we aimed to study if several single nucleotide polymorphisms (SNPs) previously associated with AD were also associated with CAA pathology. Furthermore, we also studied the influence of APOE and CLU genetic variants in apolipoprotein E (ApoE) and clusterin/apolipoprotein J (ApoJ) circulating levels and their distribution among lipoproteins. Methods The study was carried out in a multicentric cohort of 126 patients with lobar ICH and clinical suspicion of CAA. Results We observed several SNPs associated with CAA neuroimaging MRI markers [cortical superficial siderosis (cSS), enlarged perivascular spaces in the centrum semiovale (CSO-EPVS), lobar cerebral microbleeds (CMB), white matter hyperintensities (WMH), corticosubcortical atrophy and CAA-SVD burden score]. Concretely, ABCA7 (rs3764650), CLU (rs9331896 and rs933188), EPHA1 (rs11767557), and TREML2 (rs3747742) were significantly associated with a CAA-SVD burden score. Regarding circulating levels of apolipoproteins, protective AD SNPs of CLU [rs11136000 (T) and rs9331896 (C)] were significantly associated with higher HDL ApoJ content in the lobar ICH cohort. APOEε2 carriers presented higher plasma and LDL-associated ApoE levels whereas APOEε4 carriers presented lower plasma ApoE levels. Additionally, we observed that lower circulating ApoJ and ApoE levels were significantly associated with CAA-related MRI markers. More specifically, lower LDL-associated ApoJ and plasma and HDL-associated ApoE levels were significantly associated with CSO-EPVS, lower ApoJ content in HDL with brain atrophy and lower ApoE content in LDL with the extent of cSS. Discussion This study reinforces the relevance of lipid metabolism in CAA and cerebrovascular functionality. We propose that ApoJ and ApoE distribution among lipoproteins may be associated with pathological features related to CAA with higher ApoE and ApoJ levels in HDL possibly enhancing atheroprotective, antioxidative, and anti-inflammatory responses in cerebral β-amyloidosis.
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Affiliation(s)
- Anna Bonaterra-Pastra
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sònia Benítez
- Cardiovascular Biochemistry Group, Research Institute of the Hospital de Sant Pau (IIB Sant Pau), Barcelona, Spain
- Center for Biomedical Research Network on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Olalla Pancorbo
- Stroke Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
| | | | - Carla Vert
- Section of Neuroradiology, Department of Radiology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alex Rovira
- Section of Neuroradiology, Department of Radiology, Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M. Mar Freijo
- Neurovascular Group, BioCruces Health Research Institute, Barakaldo, Spain
| | - Silvia Tur
- Department of Neurology, Son Espases University Hospital, Balearic Islands, Spain
| | | | - Pere Cardona Portela
- Department of Neurology, Bellvitge University Hospital, L’Hospitalet de Llobregat, Spain
| | - Rocío Vera
- Stroke Unit, Department of Neurology, Ramón y Cajal University Hospital, Madrid, Spain
| | - Lucia Lebrato-Hernández
- Stroke Unit, Department of Neurology and Neurophysiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Juan F. Arenillas
- Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain
- Clinical Neurosciences Research Group, Department of Medicine, University of Valladolid, Valladolid, Spain
| | | | | | - Joan Martí Fàbregas
- Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Gerard Mauri
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Stroke Research Program, Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, University of Seville, Seville, Spain
- Department of Neurology, Virgen Macarena University Hospital, Seville, Spain
| | - Jose Luis Sánchez-Quesada
- Cardiovascular Biochemistry Group, Research Institute of the Hospital de Sant Pau (IIB Sant Pau), Barcelona, Spain
- Center for Biomedical Research Network on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Jose Luis Sánchez-Quesada,
| | - Mar Hernández-Guillamon
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- *Correspondence: Mar Hernández-Guillamon,
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10
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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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11
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García‐Tornel Á, Seró L, Urra X, Cardona P, Zaragoza J, Krupinski J, Gómez‐Choco M, Mas Sala N, Catena E, Palomeras E, Serena J, Hernandez‐Perez M, Boned S, Olivé‐Gadea M, Requena M, Muchada M, Tomasello A, Molina CA, Salvat‐Plana M, Escudero M, Jimenez X, Davalos A, Jovin TG, Purroy F, Abilleira S, Ribó M, Perez de la Ossa N, Jacobi MR, Sanjuan E, Santana K, Molina C, Rubiera M, Rodríguez N, Pagola J, Rodriguez‐Luna D, Maisterra O, Santamarina E, Muchada M, Juega J, Boned S, Franco AP, García‐Tornel Á, Gadea MO, Deck M, Requena M, Sala V, de la Ossa NP, Muñoz L, Millán M, Gomis M, López‐Cancio E, Dorado L, Hernández‐Pérez M, Ciurans J, Samaniego D, Canento T, Martin L, Planas A, Broto J, Sorrentino A, Paré M, Zhu N, Garrido A, Grau L, Crespo AM, Presas S, Almendrote M, Ramos A, Lucente G, Ispierto L, Lozano M, Becerra JL, Jiménez M, Rolán DV, Guanyabens N, Sanchez‐Ojanguren J, Martínez‐Piñeiro A, Forcén S, Gea M, Álvarez M, Ramos A, Lizarbe MD, Sara, Guerra R, Bragado I, Arbex A, Rodríguez L, Bustamante A, Portela PC, García HQ, Rodríguez BL, Cayuela N, Miró J, Marzal C, Paipa A, Campoy S, Núñez A, Arroyo P, Besora S, Adell V, Campdelacreu J, Martí MA, González B, Vila LB, Crespo MF, Berbel A, Urbaneja CV, Guillen N, Vidal N, Santamaria PVV, Navarro DH, Simó M, Falip M, Matas E, Ochoa NM, Gifreu A, Muñoz A, Romero L, Portell E, Perez GH, Esteve FR, Teixidor S, Talavera AS, Gómez R, Nuin XU, Vargas M, Chamorro Á, Amaro S, Llull L, Renú A, Rudilosso S, del Valle RS, Ariño H, Solà N, la Puma D, Gil F, Gómez JB, Matos N, Falgàs N, Borrego S, Sánchez A, Balasa M, Montejo C, Guasp M, Reyes D, Cervilla PS, Contador JM, Monge VAV, Ramos O, Manzanera LSR, Rodríguez A, Campello AR, Ballester GR, Trujillano ML, Steinhauer EG, Godia EC, Santiago AJO, Conde JJ, Fábregas JM, Guisado D, Prats L, Camps P, Delgado R, Domeño AM, Marín R, Cànovas D, Estela J, Ros M, Aranceta S, Espinosa J, Rubio M, Lafuente C, Barrachina O, Anguita A, Reverter A, García C, Sansa G, Hervas M, Crosas M, Delgado T, Krupinski J, Folch DSH, Gamito GM, Alvarez JT, Subirana T, Molina J, Besora S, Romero LC, Valls GG, Jover M, Sotova JJ, Sánchez SMG, Valenzuela S, Gómez‐Choco M, Mengual JJ, Font MÀ, Ruiz MIG, Zubizarreta I, González SF, Gubieras L, Cobos CE, Romo LM, Caballol N, Cano L, Leal JS, Blas YS, Izarra MT, Trigo IB, Viturro SB, Albiñana LP, Garrido MR, Cazcarra CM, Uscamaita KE, Márquez F, Coll C, Villlas MIL, Vila BS, Perna BA, Domínguezl DL, de Lera M, Foraster AC, Monge VAV, Bojaryn U, García FP, Benabdelhak I, Capdevila GM, Montesinos JS, Vázquez D, Hervás JV, González C, Quílez A, Pascual MV, Ruiz M, Riba Y, Villar MPG, García C, Roig XU, Mora MB, Guinjoan AP, Borras J, Martínez AM, Marés R, Viñas i Gaya J, Seró L, Flores A, Rodríguez DP, Castilho G, Ortega AM, Reverté S, Zaragoza J, Baiges JJ, Zaragoza J, Ozaeta GM, Escalante S, Belloch PE, Payo I, Salvado JS, Sala NM, Soler Insa JM, Vilamala ET, Navarro JA, Tabuenca HC, Sánchez TC, Ros M, Matos N, Roldán E, Rubiol 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Sergi PM, Alba PC, Lourdes QB, Cristina RB, Helena RF, del Carmen RGM, Joaquim RP, Inma RF, Amalia RF, Mariola RF, Raquel RM, Yolanda RN, Alicia RI, Albert RG, Silvia RB, de Eugenio Ramon R, Priscila RBARL, Julia SL, Carolina SJA, Daniel SS, Jordi SS, Marta SS, Enriqueta SP, Maria SB, Ruth SD, Ignacio TM, Cristina TV, Ines TSE, Soledad TT, Lluis TF, Marina TR, Anna TG, Nuria TE, Florenc U, Garazi VB, De la Paz Angel V, Fernando VG, Ingrit VG, Natalia VM, Eva VC, Jose VJM, Angela VF, Carla VG, Elisabeth VV, Jose CJF, Agusti GV, Albert GG, Laura JM, Jose MC, Felix MO, Jose MBM, Manuel ML, Jesus MRM, Carles MG, Ricardo MH, Eva MO, Ramon PP, Camilo PC, Antonio PAJ, Pol QM, Jordi RM, Sonia AA, Celia AA, Lorena AF, Joan BP, Laia BA, Francisco CV, Jaume CH, Gloria CGM, Gonzalo CM, Xavier CE, Enric CG, Montserrat CS, Carlos DS, Javier ER, del Mar ECM, Joaquin FA, Carlos FG, Patricia FP, Laura FE, Cristina FG, Marta GP, Ainhoa GG, Rafael HS, Dolça HC, Marta HR, Sonia JA, Pedro JR, Angeles LCM, Alejandro LL, Aleix LO, Rosa MRM, Daniel MM, Marta MM, Noelia ME, Olga MF, Sandra MJ, Matilde MR, Jessica NR, Maria NIR, Raquel NV, Alba PTM, Montserrat PVC, Alba PC, Angels RM, Alejandro RT, Merce RO, Mariola RF, Baltasar SG, Paola SP, Enriqueta SP, Cristina SB, Angeles SGM, Meritxell TF, Gemma TB, Jose TA, Agusti EM, Purificacion FM, Luis HP, Laura JM, Pedro LF, Alfonso LG, Felix MO, Jose MBM, Carles MG, Eva MO, Ricardo PL, Ramon PP, Joan QA, Miguel VL, Consuelo AD, Jeannette AC, Miguel AM, Anna AC, Raquel BG, Antonio BC, Del Mar CGM, Montserrat CO, Daniel CF, Marc CS, Isabel CMC, Alexander CB, Gloria CGM, Gonzalo CM, Sergio CC, Alexandre CO, Lidia CP, Rita CO, Carles DE, Javier DCP, del Mar ECM, Raquel FM, Luis GLP, Marta GP, Vallve GA, Manuela GA, Xavier GG, Carlos GM, Elena HV, Dolça HC, Cristina HG, Rafael MR, Marta MM, Daniel MM, Sergi MB, Xavier MP, Isabel MD, Maria MC, Pastalle MP, de la Cruz Raquel M, Olga MF, Javier MSF, Roger PR, Alba PTM, Feliciano PB, Monica PA, Cristina RB, Obed RP, Javier RPF, Mar RT, Sandra RP, Laura SS, Yolanda SM, Sheila SM, Eduardo SC, Soledad TT, Lluis TF, José TGP, Ricard TT, Narcis VD, Olga VE, Nuria VP, Andres BG, Marc BP, Cristina BS, Victor BA, Gemma BB, Estel BC, Alejandro CG, Esther CC, Sanchez CF, Toledo EJF, Roger ER, Xavier ERF, Mireia FS, Jordi GL, Daniel GL, Jorge HL, Alicia JLS, Joel LO, Samuel LY, Marta LV, Soto LS, Nicolas MC, Jesus MCD, Arich MP, Susana MS, Raul MM, Isabel MHM, Jose OFM, Bàrbara PB, Pedro PS, Judith RC, Marc RL, Verònica RL, Silvina RL, Gerard SC, Marc SL, Manel SR, Meritxell SG, Albert SC, Noemí SD, Gabriel SMG, Miquel TM, Maria VPA, Silvia VM, Salvat‐Plana M, Roig J, Hidalgo V, Vivanco‐Hidalgo RM, Gallofré M, Cobo E. Workflow times and outcomes in patients triaged for a suspected severe stroke. Ann Neurol 2022; 92:931-942. [DOI: 10.1002/ana.26489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/21/2022] [Accepted: 08/18/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Álvaro García‐Tornel
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
| | - Laia Seró
- Department of Neurology Hospital Universitari Joan XXIII Tarragona Spain
| | | | - Pere Cardona
- Stroke Unit Hospital Universitari Bellvitge, L'Hospitalet de Llobregat Spain
| | - Josep Zaragoza
- Department of Neurology Hospital Verge de la Cinta Tortosa Spain
| | | | - Manuel Gómez‐Choco
- Department of Neurology Complex Hospitalari Hospital Moisés Broggi Sant Joan Despí Spain
| | - Natalia Mas Sala
- Department of Neurology Hospital Sant Joan de Déu ‐ Fundació Althaia Manresa Spain
| | - Esther Catena
- Department of Neurology Consorci Sanitari Alt Penedès‐Garraf Spain
| | | | - Joaquin Serena
- Stroke Unit Hospital Universitari Josep Trueta Girona Spain
| | | | - Sandra Boned
- 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
| | - Manuel Requena
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
- Department of Interventional Neurorradiology. Hospital 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
| | - Alejandro Tomasello
- Department of Interventional Neurorradiology. Hospital 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
| | - Mercè Salvat‐Plana
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS) CIBER Epidemiología y Salud Pública (CIBERESP) Barcelona Spain
| | | | | | - Antoni Davalos
- Stroke Unit Hospital Germans Trias i Pujol Badalona Barcelona Spain
| | - Tudor G Jovin
- Neurological Institute Cooper University Hospital Camden New Jersey
| | - Francesc Purroy
- Stroke Unit. Department of Neurology Hospital Universitari Arnau de Vilanova de Lleida Lleida Spain
| | - Sonia Abilleira
- Stroke Program, Catalan Health Department, Agency for Health Quality and Assesment of Catalonia (AQuAS) CIBER Epidemiología y Salud Pública (CIBERESP) Barcelona Spain
| | - Marc Ribó
- Stroke Unit. Department of Neurology. Hospital Universitari Vall d'Hebron. Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain
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Sarraj A, Hassan AE, Abraham MG, Cardona Portela P, Manning NW, Cordato D, Kleinig TJ, Goyal N, Blackburn S, McCullough-Hicks ME, Ribo M, Wu TY, Blasco J, Sangha N, Arenillas JF, Wallace A, Pujara DK, Shaker F, de Lera Alfonso M, Renu A, Olivé Gadea M, Gibson D, Lechtenberg CG, Maali LN, Abdulrazzak MA, Almaghrabi TS, Beharry J, Krishnaiah B, Miller M, Khalil N, Sharma GJ, Katsanos AH, Fadhil A, Duncan KR, Hu Y, sitton CW, Martin-schild SB, Tsivgoulis GK, Mitchell PJ, Arthur AS, Parsons M, Grotta JC, Campbell BC, Albers GW. Abstract 36: Endovascular Thrombectomy Beyond 24 Hours From Last Known Well:
A Pooled Multicenter International Cohort. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Limited data are available on endovascular thrombectomy (EVT) efficacy and safety in large vessel occlusion (LVO) patients presenting >24hr from last known well (LKW). We compared outcomes between patients receiving EVT and best medical management (MM) in a multicenter international cohort.
Methods:
Consecutive patients with anterior circulation LVO presenting >24h after LKW from 13 centers from 7/2012-4/2021 were analyzed. Multivariable models for 90d mRS distribution and symptomatic ICH were adjusted for age, NIHSS, glucose, IV tPA, transfer status, clot location, time from LKW, CT ASPECTS and ischemic core (rCBF<30%) and Tmax >6s volumes.
Results:
Of 240 patients with a median (IQR) LKW to presentation 28.3h (24.9-38.2), 153 (64%) received EVT. Baseline characteristics were similar except for NIHSS (EVT: 13 (8-20) vs MM: 17 (10-22), p=0.005), CT ASPECTS (EVT: 8(6-9) vs MM: 4(3-6), p<0.001) and ischemic core 2.5(0-13) vs 15(0-71) mL, p<0.001. EVT was associated with a better shift in 90d mRS (acOR: 2.45, 95% CI=1.42-4.22, p=0.001), higher functional independence (42% vs 10%, aOR: 4.84, 95% CI=2.02-11.64, p<0.001) and numerically lower mortality (22% vs 42%, aOR: 0.50, 95% CI=0.23-1.06, p=0.071), Fig 1A. However, EVT was associated with numerically higher sICH (5.5% vs 0%, p=0.10). Following EVT, 82% achieved successful reperfusion (mTICI 2b-3), which was associated with better shift in 90d mRS (acOR: 5.82, 95% CI: 1.77-19.10, p=0.004), higher functional independence (44% vs 22%, aOR: 5.03, 95% CI: 0.87-29.12, p=0.07) and lower mortality (20% vs 52%, aOR: 0.08, 95% CI: 0.01-0.57, p=0.01), Fig 1B.
Conclusions:
EVT may be associated with better functional outcomes, despite numerically increased risk of sICH in patients presenting with anterior circulation LVO beyond 24 hours. Further prospective studies are warranted.
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Affiliation(s)
- Amrou Sarraj
- Neurology, Case Western - Univ Hosps, Cleveland, OH
| | - Ameer E Hassan
- Neurology, Univ of Texas Rio Grande Valley - Valley Baptist Med Cntr, Harlingen, TX
| | | | | | | | | | | | - Nitin Goyal
- Neurology, The Univ of Tennessee Health Science Cntr and Semmes-Murphey Clinic, Memphis, TN
| | | | | | - Marc Ribo
- Hosp Universitari Vall d'Hebron, Barcelona, Spain
| | - Teddy Y Wu
- Christchurch Hosp, Christchurch, New Zealand
| | | | | | | | - Adam Wallace
- Neurointerventional Surgery, Ascension Columbia St. Mary’s Hosp, Milwaukee, WI
| | | | - Faris Shaker
- Neurosurgery, McGovern Med Sch at UTHealth, Houston, TX
| | | | | | | | - Daniel Gibson
- Neurointerventional Surgery, Ascension Columbia St. Mary’s Hosp, Milwaukee, WI
| | | | | | | | | | - James Beharry
- Neurology, The Royal Melbourne Hosp Univ of Melbourne, Parkville, Australia
| | | | - Megan Miller
- Neurology, Liverpool Hosp - UNSW Medicine, Liverpool, Australia
| | - Najwa Khalil
- Neurology, Case Western - Univ Hosps, Cleveland, OH
| | - Gagan J Sharma
- The Royal Melbourne Hosp Univ of Melbourne, Parkville, Australia
| | | | - Ali Fadhil
- Neurology, Case Western - Univ Hosps, Cleveland, OH
| | | | - Yin Hu
- Neurosurgery, Case Western - Univ Hosps, Cleveland, OH
| | | | | | | | - Peter J Mitchell
- The Royal Melbourne Hosp Univ of Melbourne, Parkville, Australia
| | - Adam S Arthur
- Neurosurgery, The Univ of Tennessee Health Science Cntr and Semmes-Murphey Clinic, Memphis, TN
| | - Mark Parsons
- Neurology, Liverpool Hosp - UNSW Medicine, Liverpool Sydney, Australia
| | | | - Bruce C Campbell
- The Royal Melbourne Hosp Univ of Melbourne, Parkville, Australia
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13
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Marazuela P, Bonaterra-Pastra A, Faura J, Penalba A, Pizarro J, Pancorbo O, Rodríguez-Luna D, Vert C, Rovira A, Pujadas F, Freijo MM, Tur S, Martínez-Zabaleta M, Cardona Portela P, Vera R, Lebrato-Hernández L, Arenillas JF, Pérez-Sánchez S, Montaner J, Delgado P, Hernández-Guillamon M. Circulating AQP4 Levels in Patients with Cerebral Amyloid Angiopathy-Associated Intracerebral Hemorrhage. J Clin Med 2021; 10:jcm10050989. [PMID: 33801197 PMCID: PMC7957864 DOI: 10.3390/jcm10050989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 12/27/2022] Open
Abstract
Cerebral amyloid angiopathy (CAA) is a major cause of lobar intracerebral hemorrhage (ICH) in elderly patients. Growing evidence suggests a potential role of aquaporin 4 (AQP4) in amyloid-beta-associated diseases, including CAA pathology. Our aim was to investigate the circulating levels of AQP4 in a cohort of patients who had suffered a lobar ICH with a clinical diagnosis of CAA. AQP4 levels were analyzed in the serum of 60 CAA-related ICH patients and 19 non-stroke subjects by enzyme-linked immunosorbent assay (ELISA). The CAA–ICH cohort was divided according to the time point of the functional outcome evaluation: mid-term (12 ± 18.6 months) and long-term (38.5 ± 32.9 months) after the last ICH. Although no differences were found in AQP4 serum levels between cases and controls, lower levels were found in CAA patients presenting specific hemorrhagic features such as ≥2 lobar ICHs and ≥5 lobar microbleeds detected by magnetic resonance imaging (MRI). In addition, CAA-related ICH patients who presented a long-term good functional outcome had higher circulating AQP4 levels than subjects with a poor outcome or controls. Our data suggest that AQP4 could potentially predict a long-term functional outcome and may play a protective role after a lobar ICH.
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Affiliation(s)
- Paula Marazuela
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.M.); (A.B.-P.); (J.F.); (A.P.); (J.P.); (J.M.); (P.D.)
| | - Anna Bonaterra-Pastra
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.M.); (A.B.-P.); (J.F.); (A.P.); (J.P.); (J.M.); (P.D.)
| | - Júlia Faura
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.M.); (A.B.-P.); (J.F.); (A.P.); (J.P.); (J.M.); (P.D.)
| | - Anna Penalba
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.M.); (A.B.-P.); (J.F.); (A.P.); (J.P.); (J.M.); (P.D.)
| | - Jesús Pizarro
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.M.); (A.B.-P.); (J.F.); (A.P.); (J.P.); (J.M.); (P.D.)
| | - Olalla Pancorbo
- Stroke Unit, Department of Neurology, Vall d’Hebron Hospital, 08035 Barcelona, Spain; (O.P.); (D.R.-L.)
| | - David Rodríguez-Luna
- Stroke Unit, Department of Neurology, Vall d’Hebron Hospital, 08035 Barcelona, Spain; (O.P.); (D.R.-L.)
| | - Carla Vert
- Neuroradiology, Department of Radiology, Vall d’Hebron Hospital, 08035 Barcelona, Spain; (C.V.); (A.R.)
| | - Alex Rovira
- Neuroradiology, Department of Radiology, Vall d’Hebron Hospital, 08035 Barcelona, Spain; (C.V.); (A.R.)
| | - Francesc Pujadas
- Dementia Unit, Neurology Department, Vall d’Hebron Hospital, 08035 Barcelona, Spain;
| | - M. Mar Freijo
- Neurovascular Group, Biocruces Health Research Institute, 48903 Barakaldo, Spain;
| | - Silvia Tur
- Neurology, Son Espases University Hospital, 07120 Balearic Islands, Spain;
| | | | - Pere Cardona Portela
- Department of Neurology, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain;
| | - Rocío Vera
- Stroke Unit, Department of Neurology, Ramon y Cajal University Hospital, 28034 Madrid, Spain;
| | | | - Juan F. Arenillas
- Stroke Program, Department of Neurology, Hospital Clínico Universitario, 47003 Valladolid, Spain;
- Clinical Neurosciences Research Group, Department of Medicine, University of Valladolid, 47003 Valladolid, Spain
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.M.); (A.B.-P.); (J.F.); (A.P.); (J.P.); (J.M.); (P.D.)
- Department of Neurology, Virgen Macarena University Hospital, 41009 Sevilla, Spain;
- Stroke Research Program, Institute of Biomedicine of Sevilla, IBiS, Virgen del Rocío University Hospital, University of Sevilla, 41009 Sevilla, Spain
| | - Pilar Delgado
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.M.); (A.B.-P.); (J.F.); (A.P.); (J.P.); (J.M.); (P.D.)
| | - Mar Hernández-Guillamon
- Neurovascular Research Laboratory, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.M.); (A.B.-P.); (J.F.); (A.P.); (J.P.); (J.M.); (P.D.)
- Correspondence:
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14
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Ramos-Araque ME, Siegler JE, Ribo M, Requena M, López C, de Lera M, Arenillas JF, Pérez IH, Gómez-Vicente B, Talavera B, Portela PC, Guillen AN, Urra X, Llull L, Renú A, Nguyen TN, Jillella D, Nahab F, Nogueira R, Haussen D, Then R, Thon JM, Esparragoza LR, Hernández-Pérez M, Bustamante A, Mansour OY, Megahed M, Hassan T, Liebeskind DS, Hassan A, Bushnaq S, Osman M, Vazquez AR. Stroke etiologies in patients with COVID-19: the SVIN COVID-19 multinational registry. BMC Neurol 2021; 21:43. [PMID: 33514335 PMCID: PMC7846488 DOI: 10.1186/s12883-021-02075-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/19/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Coronavirus disease 2019 (COVID-19) is associated with a small but clinically significant risk of stroke, the cause of which is frequently cryptogenic. In a large multinational cohort of consecutive COVID-19 patients with stroke, we evaluated clinical predictors of cryptogenic stroke, short-term functional outcomes and in-hospital mortality among patients according to stroke etiology. METHODS We explored clinical characteristics and short-term outcomes of consecutively evaluated patients 18 years of age or older with acute ischemic stroke (AIS) and laboratory-confirmed COVID-19 from 31 hospitals in 4 countries (3/1/20-6/16/20). RESULTS Of the 14.483 laboratory-confirmed patients with COVID-19, 156 (1.1%) were diagnosed with AIS. Sixty-one (39.4%) were female, 84 (67.2%) white, and 88 (61.5%) were between 60 and 79 years of age. The most frequently reported etiology of AIS was cryptogenic (55/129, 42.6%), which was associated with significantly higher white blood cell count, c-reactive protein, and D-dimer levels than non-cryptogenic AIS patients (p=0.05 for all comparisons). In a multivariable backward stepwise regression model estimating the odds of in-hospital mortality, cryptogenic stroke mechanism was associated with a fivefold greater odds in-hospital mortality than strokes due to any other mechanism (adjusted OR 5.16, 95%CI 1.41-18.87, p = 0.01). In that model, older age (aOR 2.05 per decade, 95%CI 1.35-3.11, p < 0.01) and higher baseline NIHSS (aOR 1.12, 95%CI 1.02-1.21, p = 0.01) were also independently predictive of mortality. CONCLUSIONS Our findings suggest that cryptogenic stroke among COVID-19 patients carries a significant risk of early mortality.
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Affiliation(s)
- María E Ramos-Araque
- Institute of Biomedical Research of Salamanca, Department of Neurology, Hospital Universitario de Salamanca, Salamanca, Spain
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - James E Siegler
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA.
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain
- Departament of Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain
- Departament of Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Cristina López
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mercedes de Lera
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Isabel Hernández Pérez
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Beatriz Gómez-Vicente
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Blanca Talavera
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Ana Nuñez Guillen
- Department of Neurology, Hospital Universitari, Bellvitge, Barcelona, Spain
| | - Xabier Urra
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Laura Llull
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Arturo Renú
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Thanh N Nguyen
- Department of Neurology, Department of Radiology, Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Dinesh Jillella
- Department of Neurology, Emory University School of Medicine, Atlanta, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, USA
| | - Raul Nogueira
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | - Diogo Haussen
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | - Ryna Then
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jesse M Thon
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
| | - Luis Rodríguez Esparragoza
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Maria Hernández-Pérez
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Alejandro Bustamante
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ossama Yassin Mansour
- Neurology Department, Stroke and neurointervention unit, Alexandria University, Alexandria, Egypt
| | - Mohammed Megahed
- Critical care Department, Alexandria University, Alexandria, Egypt
| | - Tamer Hassan
- Neurosurgery Department, Stroke and Neurointervention unit, Alexandria University, Alexandria, Egypt
| | - David S Liebeskind
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, USA
| | - Ameer Hassan
- Department of Clinical Neuroscience Research, Valley Baptist Medical Center, Harlingen, TX, USA
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Saif Bushnaq
- Neuroscience Institute, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH, USA
| | - Mohamed Osman
- Neuroscience Institute, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH, USA
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15
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Abstract
BACKGROUND Sleep-disordered breathing (SDB) is a disease of increasing importance and it is frequent in stroke patients. SDB is being recognized as an independent risk factor for several clinical consequences, including cardiovascular and cerebrovascular disease. METHODS The present review summarizes the current evidence for an independent association between SDB and stroke, defining SDB subgroups, mechanisms, confounding factors and other epidemiological aspects. We analyze stroke outcome and prognosis in SDB patients. A search for recent data on this issue was made in several population-based studies and reference lists of articles. RESULTS Many recent studies have shown an association between SDB and stroke. Moreover, there is a high prevalence of sleep apnea in patients with stroke. The pathogenesis of stroke in obstructive sleep apnea syndrome is not completely understood and likely to be multifactorial. Several mechanisms like hemodynamic disturbances and inflammatory or endothelial dysfunction could be involved. The presence of SDB in stroke patients may lead to a poor outcome and recurrence. Noninvasive treatments such as continuous positive airway pressure may decrease the risk of stroke in terms of secondary, and possibly, primary prevention. CONCLUSIONS SDB is associated with cerebrovascular morbidity and an unfavorable clinical course. The presence of SDB should be systematically screened in patients with acute stroke. Further studies are needed to determine whether continuous positive airway pressure treatment ameliorates stroke outcome and prognosis.
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