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Flint AC, Faigeles BS, Cullen SP, Kamel H, Rao VA, Gupta R, Smith WS, Bath PM, Donnan GA, Lees K, Alexandrov A, Bath P, Bluhmki E, Bornstein N, Claesson L, Davis S, Donnan G, Diener H, Fisher M, Gregson B, Grotta J, Hacke W, Hennerici M, Hommel M, Kaste M, Lyden P, Marler J, Muir K, Sacco R, Shuaib A, Teal P, Wahlgren N, Warach S, Weimar C. THRIVE Score Predicts Ischemic Stroke Outcomes and Thrombolytic Hemorrhage Risk in VISTA. Stroke 2013; 44:3365-9. [DOI: 10.1161/strokeaha.113.002794] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background and Purpose—
In previous studies, the Totaled Health Risks in Vascular Events (THRIVE) score has shown broad utility, allowing prediction of clinical outcome, death, and risk of hemorrhage after tissue-type plasminogen activator (tPA) treatment, irrespective of the type of acute stroke therapy applied to the patient.
Methods—
We used data from the Virtual International Stroke Trials Archive to further validate the THRIVE score in a large cohort of patients receiving tPA or no acute treatment, to confirm the relationship between THRIVE and hemorrhage after tPA, and to compare the THRIVE score with several other available outcome prediction scores.
Results—
The THRIVE score strongly predicts clinical outcome (odds ratio, 0.55 for good outcome [95% CI, 0.53–0.57];
P
<0.001), mortality (odds ratio, 1.57 [95% confidence interval, 1.50–1.64];
P
<0.001), and risk of intracerebral hemorrhage after tPA (odds ratio, 1.34 [95% confidence interval, 1.22–1.46];
P
<0.001). The relationship between THRIVE score and outcome is not influenced by the independent relationship of tPA administration and outcome. In receiver operator characteristic curve analysis, the THRIVE score was superior to several other available outcome prediction scores in the prediction of clinical outcome and mortality.
Conclusions—
The THRIVE score is a simple-to-use tool to predict clinical outcome, mortality, and risk of hemorrhage after thrombolysis in patients with ischemic stroke. Despite its simplicity, the THRIVE score performs better than several other outcome prediction tools. A free Web calculator for the THRIVE score is available at
http://www.thrivescore.org
.
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Saver JL, Jovin TG, Smith WS, Albers GW, Baron JC, Boltze J, Broderick JP, Davis LA, Demchuk AM, DeSena S, Fiehler J, Gorelick PB, Hacke W, Holt B, Jahan R, Jing H, Khatri P, Kidwell CS, Lees KR, Lev MH, Liebeskind DS, Luby M, Lyden P, Megerian JT, Mocco J, Muir KW, Rowley HA, Ruedy RM, Savitz SI, Sipelis VJ, Shimp SK, Wechsler LR, Wintermark M, Wu O, Yavagal DR, Yoo AJ. Stroke treatment academic industry roundtable: research priorities in the assessment of neurothrombectomy devices. Stroke 2013; 44:3596-601. [PMID: 24193797 PMCID: PMC4142766 DOI: 10.1161/strokeaha.113.002769] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE The goal of the Stroke Treatment Academic Industry Roundtable (STAIR) meetings is to advance the development of stroke therapies. At STAIR VIII, consensus recommendations were developed for clinical trial strategies to demonstrate the benefit of endovascular reperfusion therapies for acute ischemic stroke. SUMMARY OF REVIEW Prospects for success with forthcoming endovascular trials are robust, because new neurothrombectomy devices have superior reperfusion efficacy compared with earlier-generation interventions. Specific recommendations are provided for trial designs in 3 populations: (1) patients undergoing intravenous fibrinolysis, (2) early patients ineligible for or having failed intravenous fibrinolysis, and (3) wake-up and other late-presenting patients. Among intravenous fibrinolysis-eligible patients, key principles are that CT or MRI confirmation of target arterial occlusions should precede randomization; endovascular intervention should be pursued with the greatest rapidity possible; and combined intravenous and neurothrombectomy therapy is more promising than neurothrombectomy alone. Among patients ineligible for or having failed intravenous fibrinolysis, scientific equipoise was affirmed and the need to randomize all eligible patients emphasized. Vessel imaging to confirm occlusion is mandatory, and infarct core and penumbral imaging is desirable in later time windows. Additional STAIR VIII recommendations include approaches to test multiple devices in a single trial, utility weighting of disability end points, and adaptive designs to delineate time and tissue injury thresholds at which benefits from intervention no longer accrue. CONCLUSIONS Endovascular research priorities in acute ischemic stroke are to perform trials testing new, highly effective neuro thrombectomy devices rapidly deployed in patients confirmed to have target vessel occlusions.
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Flint AC, Xiang B, Gupta R, Nogueira RG, Lutsep HL, Jovin TG, Albers GW, Liebeskind DS, Sanossian N, Smith WS. THRIVE score predicts outcomes with a third-generation endovascular stroke treatment device in the TREVO-2 trial. Stroke 2013; 44:3370-5. [PMID: 24072003 DOI: 10.1161/strokeaha.113.002796] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Several outcome prediction scores have been tested in patients receiving acute stroke treatment with previous generations of endovascular stroke treatment devices. The TREVO-2 trial was a randomized controlled trial comparing a novel endovascular stroke treatment device (the Trevo device) to a previous-generation endovascular stroke treatment device (the Merci device). METHODS We used data from the TREVO-2 trial to validate the Totaled Health Risks in Vascular Events (THRIVE) score in patients receiving treatment with a third-generation endovascular stroke treatment device and to compare THRIVE to other predictive scores. We used logistic regression to model outcomes and compared score performance with receiver operating characteristic curve analysis. RESULTS In the TREVO-2 trial, the THRIVE score strongly predicts clinical outcome and mortality. The relationship between THRIVE score and outcome is not influenced by either success of recanalization or the type of device used (Trevo versus Merci). The superiority of the Trevo device to the Merci device is evident particularly among patients with a low-to-moderate THRIVE score (0-5; 53.8% good outcome with Trevo versus 27.5% good outcome with Merci). In receiver operating characteristic curve analysis, the THRIVE score was comparable or superior to several other outcome prediction scores (HIAT, HIAT-2, SPAN-100, and iScore). CONCLUSIONS The THRIVE score strongly predicts clinical outcome and mortality in the TREVO-2 trial. Taken together with THRIVE validation data from patients receiving intravenous tissue-type plasminogen activator or no acute treatment, the THRIVE score has broad predictive power in patients with acute ischemic stroke, which is likely because THRIVE reflects a set of strong nonmodifiable predictors of stroke outcome. A free Web calculator for the THRIVE score is available at http://www.thrivescore.org.
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González RG, Furie KL, Goldmacher GV, Smith WS, Kamalian S, Payabvash S, Harris GJ, Halpern EF, Koroshetz WJ, Camargo ECS, Dillon WP, Lev MH. Good outcome rate of 35% in IV-tPA-treated patients with computed tomography angiography confirmed severe anterior circulation occlusive stroke. Stroke 2013; 44:3109-13. [PMID: 24003051 DOI: 10.1161/strokeaha.113.001938] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE To determine the effect of intravenous tissue plasminogen activator (IV-tPA) on outcomes in patients with severe major anterior circulation ischemic stroke. METHODS Prospectively, 649 patients with acute stroke had admission National Institutes of Health stroke scale (NIHSS) scores, noncontrast computed tomography (CT), CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale. IV-tPA treatment decisions were made before CTA, at the time of noncontrast CT scanning, as per routine clinical protocol. Severe symptoms were defined as NIHSS>10. Poor outcome was defined as modified Rankin scale >2. Major occlusions were identified on CTA. Univariate and multivariate stepwise-forward logistic regression analyses of the full cohort were performed. RESULTS Of 649 patients, 188 (29%) patients presented with NIHSS>10, and 64 out of 188 (34%) patients received IV-tPA. Admission NIHSS, large artery occlusion, and IV-tPA all independently predicted good outcomes; however, a significant interaction existed between IV-tPA and occlusion (P<0.001). Of the patients who presented with NIHSS>10 with anterior circulation occlusion, twice the percentage had good outcomes if they received IV-tPA (17 out of 49 patients, 35%) than if they did not (13 out of 77 patients, 17%; P=0.031). The number needed to treat was 7 (95% confidence interval, 3-60). CONCLUSIONS IV-tPA treatment resulted in significantly better outcomes in patients with severely symptomatic stroke with major anterior circulation occlusions. The 35% good outcome rate was similar to rates found in endovascular therapy trials. Vascular imaging may help in patient selection and stratification for trials of IV-thrombolytic and endovascular therapies.
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Navi BB, Kamel H, Hemphill JC, Smith WS. Trajectory of functional recovery after hospital discharge for subarachnoid hemorrhage. Neurocrit Care 2013; 17:343-7. [PMID: 22932992 DOI: 10.1007/s12028-012-9772-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although there are extensive data on long-term disability after subarachnoid hemorrhage (SAH), there are few data on the trajectory of functional recovery after hospital discharge. METHODS From October 2009 to April 2010, we prospectively followed consecutive patients with non-traumatic SAH discharged from a university hospital. Modified Rankin Scale (mRS) scores were calculated at discharge from chart review and at 6 months by standardized telephone interview. Good functional status was defined as a mRS score of 0-2, and poor status as an mRS score of 3-6. Descriptive statistics were used to assess the trajectory of functional recovery and determine the proportion of patients whose functional status improved from poor to good. RESULTS Among 52 patients with non-traumatic SAH (79 % aneurysmal) who were discharged alive, most (71 %) were discharged home. Median (IQR) mRS score was 3 (2-4) at discharge and 2 (1-2) at 6 months. Some functional recovery (any improvement in mRS score) was seen in most patients (83 %; 95 % CI, 72-93 %). Of the 28 patients with poor functional status at discharge, 16 (57 %) improved to good functional status at 6 months. All patients with Hunt-Hess grade 4 or 5 hemorrhages (n = 14) had poor functional status at discharge, but half (95 % CI, 20-80 %) recovered to a good functional status at 6 months. CONCLUSIONS Although our sample size is small, our findings suggest that a substantial proportion of patients with SAH who are disabled at discharge go on to regain functional independence within 6 months.
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Andrews CM, Jauch EC, Hemphill JC, Smith WS, Weingart SD. Emergency neurological life support: intracerebral hemorrhage. Neurocrit Care 2013; 17 Suppl 1:S37-46. [PMID: 22965322 DOI: 10.1007/s12028-012-9757-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Intracerebral hemorrhage (ICH) is a subset of stroke resulting from bleeding within the brain parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, reversal of coagulopathy, and proper diagnosis. ICH was chosen as an emergency neurological life support (ENLS) protocol because intervention within the first critical hour may improve outcome, and it is helpful to have a protocol to drive care quickly and efficiently.
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Huff JS, Stevens RD, Weingart SD, Smith WS. Emergency neurological life support: approach to the patient with coma. Neurocrit Care 2013; 17 Suppl 1:S54-9. [PMID: 22932989 DOI: 10.1007/s12028-012-9755-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Coma is an acute failure of neuronal systems governing arousal and awareness and represents a neurological emergency. When encountering a comatose patient, the clinician must have an organized approach to detect easily remedial causes, prevent ongoing neurologic injury, and determine a hierarchy of diagnostic tests, treatments, and neuromonitoring. Coma was chosen as an Emergency Neurological Life Support (ENLS) protocol because timely medical and surgical interventions can be life-saving, and the initial work-up of such patients is critical to establishing a correct diagnosis.
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58
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Swadron SP, LeRoux P, Smith WS, Weingart SD. Emergency neurological life support: traumatic brain injury. Neurocrit Care 2013; 17 Suppl 1:S112-21. [PMID: 22975830 DOI: 10.1007/s12028-012-9760-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Traumatic brain injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.
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Seder DB, Riker RR, Jagoda A, Smith WS, Weingart SD. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care 2013; 17 Suppl 1:S4-20. [PMID: 22972019 DOI: 10.1007/s12028-012-9753-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Airway management is central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Therefore, airway, ventilation, and sedation were chosen as an Emergency Neurological Life Support (ENLS) protocol. Reviewed topics include airway management; the decision to intubate; when and how to intubate with attention to cardiovascular status; mechanical ventilation settings; and the use of sedation, including how to select sedative agents based on the patient's neurological status.
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Liebeskind DS, Sanossian N, Jovin TG, Lutsep HL, Gupta R, Walker GA, Albers GW, Smith WS, Nogueira RG. Abstract 167: Collateral Flow and ASPECTS of Infarct Evolution Dominate Time to Reperfusion in Outcomes of TREVO2. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.a167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Definitive reperfusion, or revascularization associated with good clinical outcomes, is likely dependent on key imaging variables. ASPECTS score on imaging before and after revascularization may chronicle the extent of ischemic injury in acute stroke. We hypothesized that ASPECTS and other key imaging variables would be associated with clinical outcome after endovascular therapy in the TREVO2 trial.
Methods:
TREVO2 utilized independent core labs for CT/MRI and angiography central review. Retrospective review of ASPECTS by expert consensus on baseline and 24 hour imaging was conducted in anterior circulation cases, blinded to all other data. Univariate and multivariate analyses determined the impact of key imaging variables (baseline ASPECTS, ASPECTS ≥ 8, collaterals, time to TICI 2a reperfusion or greater, final TICI, 24-hour ASPECTS) on good clinical outcome (mRS 0-2) and mortality at day 90.
Results:
166/177 cases in TREVO2 were anterior circulation occlusions. Baseline ASPECTS was ≤ 7 in 83/166 (50%) cases. Baseline ASPECTS score ≤ 7 was unrelated to age, gender, or any other clinical parameter other than NIHSS score (median 19 (17-23) vs. 17 (13-20) for ASPECTS > 7, p<0.001) and clot location (more ICA than M2 occlusions, p=0.044). Baseline ASPECTS ≤ 7 was also unrelated to post-device TICI or post-procedure SICH. Baseline ASPECTS ≤ 7 was associated with asymptomatic hemorrhage at 24 hours (63.9% vs. 37.3%, p=0.001), 90-day mortality (35.4% vs. 19.3%, p=0.024), and less frequent good clinical outcome (21.5% vs. 42.0%, p=0.007). Univariate imaging predictors of good clinical outcome at day 90 included baseline ASPECTS (OR 1.82, p<0.001), baseline ASPECTS ≥ 8 (OR 2.64, p=0.006), collateral grade (OR 1.85, p=0.003), post-procedure TICI (OR 2.11, p<0.001), 24-hour ASPECTS (OR 1.67, p<0.001) and 24-hour ASPECTS ≥ 8 (OR 4.38, p<0.001). Time to TICI 2a or greater was not predictive. Multivariate analyses showed that 24-hour ASPECTS (OR 1.70, p<0.001) and post-procedure TICI (OR 2.49, p=0.003) best predicted good outcome.
Conclusions:
Better ASPECTS (≥ 8), collaterals, and reperfusion are strongly associated with good clinical outcome whereas the large proportion (50%) of TREVO2 cases with baseline ASPECTS ≤ 7 likely influenced mortality.
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Lutsep HL, Nogueira RG, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS. Abstract WP13: Stroke Severity and Revascularization are the Strongest Predictors of Outcome in Large Vessel Occlusion Strokes: Post-Hoc Analysis of the TREVO 2 Trial. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.awp13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction.:
The Trevo Retriever showed higher recanalization rates and better outcomes than the Merci Retriever in patients with ischemic stroke due to large vessel occlusion (LVO) in TREVO 2.
Hypothesis.:
We assessed the hypothesis that except for device-related variables, predictors of good outcome would be similar in TREVO 2 and single arm Merci Retriever studies.
Methods.:
The study evaluated predictors of good outcome, modified Rankin Scale (mRS) 0-2 at 90 days, in TREVO 2 including those with ischemic stroke due to LVO aged 18-85 years with a National Institutes of Health Stroke Scale Score (NIHSS) 8-29 and a first device treatment pass within 8 hours of symptom onset. A secondary analysis investigated mortality predictors. Variables included baseline characteristics of age, sex, NIHSS, IV tPA use, occlusion side, most proximal occlusion site, stroke etiology, body mass index, systolic blood pressure (BP), diastolic BP, glucose; history including hypertension, diabetes, dyslipidemia, smoking, congestive heart failure (CHF), atrial fibrillation, previous coronary or cerebral ischemia; and procedural characteristics of time from symptom onset to arterial puncture, time to TICI ≥2 or end of procedure, device allocation, intubation status, rescue therapy usage and post device revascularization success TICI ≥ 2 per core lab. Variables were assessed with univariate analysis for association with mRS 0-2 and mortality and those with a p-value of <0.15 were eligible for the multivariate model.
Results.:
TREVO 2 data were available for 168 patients. Variables significant on multivariate analysis for an association with good outcome were baseline NIHSS (OR 0.76, 95% CI 0.67, 0.86), post device revascularization success per core lab (OR 117.6, 95% CI 8.40, 1645), diabetes (OR 0.12, 95% CI 0.03, 0.41), intubation (OR 0.11, 95% CI 0.03, 0.41) and left hemisphere involvement (OR 5.11, 95% CI 1.77, 14.71). Predictors of mortality included baseline NIHSS and left hemisphere involvement but also age and CHF.
Conclusions.:
While age did not appear as a predictor of good outcome and diabetes was negatively associated with it for the first time in a Merci analysis, predictors of favorable outcome in TREVO 2 were similar to those previously reported for the Merci Retriever.
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Liebeskind DS, Scalzo F, Sanossian N, Gupta R, Jovin TG, Walker GA, Albers GW, Lutsep HL, Smith WS, Nogueira RG. Abstract WP39: Perfusion Angiography in TREVO2: Quantitative Reperfusion After Endovascular Therapy in Acute Stroke. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.awp39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Effective reperfusion is the ultimate therapeutic strategy for acute ischemic stroke, yet endovascular trials have been limited by the use of categorical scales for angiographic outcomes. Semi-automated perfusion angiography (PA) software can objectively quantify reperfusion from routine angiography. We studied feasibility and performance of PA software to evaluate angiographic and associated clinical outcomes in the multicenter TREVO2 trial.
Methods:
Core lab angiography DICOM data in TREVO2 was retrospectively used to identify anterior circulation cases with adequate temporal resolution at both baseline and after revascularization with mechanical thrombectomy. CBF was computed by deconvolution of contrast-intensity data up to 3 sec to correlate with TICI and avoid collaterals. Regions of interest (ROI) outlined areas of hypoperfusion on baseline AP and lateral angiography to map reperfusion onto identical post-procedure angiography runs. A nonlinear cross-validation model was used to map output from the ROI to a single reperfusion metric (PA CBF
3
).
Results:
148/178 (83%) patients with anterior circulation stroke in TREVO2 had DICOM angiography data with complete temporal information on serial runs at baseline and post-procedure that could be processed with the software. Core lab TICI scores in this dataset ranged from 0-3 (0, n=6; 1, n=7; 2a, n=40; 2b, n=83; 3, n=12). The continuous PA CBF
3
metric or reperfusion score ranged from 0-8.6 (mean 3.7±1.2), capturing hyperperfusion and heterogeneity.
Overall, PA CBF
3
closely correlated with TICI (ρ=0.69, p<0.001), yet provided a continuous measure that better discriminated angiographic outcomes. Software performance and PA CBF
3
results were equivalent in ICA, M1 and M2 occlusions treated in TREVO2.
Conclusions:
PA can objectively quantify heterogeneity of reperfusion in a multicenter trial, providing a continuous metric that discriminates angiographic outcomes better than TICI.
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Zaidat OO, Castonguay AC, Fitzsimmons BF, Woodward BK, Wang Z, Killer-Oberpfalzer M, Wakhloo A, Gupta R, Kirshner H, Eliasziw M, Thomas Megerian J, Shetty S, Yoklavich Guilhermier M, Barnwell S, Smith WS, Gress DR. Design of the Vitesse Intracranial Stent Study for Ischemic Therapy (VISSIT) trial in symptomatic intracranial stenosis. J Stroke Cerebrovasc Dis 2012; 22:1131-9. [PMID: 23261207 DOI: 10.1016/j.jstrokecerebrovasdis.2012.10.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 10/04/2012] [Accepted: 10/31/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Patients with high-grade symptomatic intracranial stenosis (≥ 70%) have an increased risk of recurrent stroke despite medical treatment with antiplatelet or anticoagulant therapy. Intracranial stenting has been proposed as a viable treatment option for this high-risk patient population; however, evaluation of this therapy in randomized multicenter trials is needed. In this article, we present the design and methods of the Vitesse Intracranial Stent Study for Ischemic Therapy (VISSIT) trial for symptomatic intracranial stenosis. METHODS The VISSIT trial is a randomized control study designed to evaluate the safety, probable benefit, and effectiveness of the PHAROS Vitesse neurovascular balloon-expandable stent system plus medical therapy versus medical therapy alone in patients with cerebral or retinal ischemia due to neurovascular stenosis (≥ 70%) for preventing the primary composite end point: stroke in the same territory (distal to the target lesion) as the presenting event within 12 months of randomization or hard transient ischemic attack in the same territory (distal to the target lesion) as the presenting event from day 2 through month 12 postrandomization. RESULTS Enrollment began in February 2009 and was halted in January 2012 with 112 subjects enrolled into the study. Clinical follow-up will continue for the planned period of 12 months postrandomization. CONCLUSIONS The VISSIT trial may provide valuable insight into the use of balloon-expandable intracranial stent as a treatment option for high-risk patients. Lessons learned from this trial may better guide future clinical trial design on best patient selection, stenting techniques, and periprocedural management.
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Kamel H, Navi BB, Elijovich L, Josephson SA, Yee AH, Fung G, Johnston SC, Smith WS. Pilot randomized trial of outpatient cardiac monitoring after cryptogenic stroke. Stroke 2012. [PMID: 23192756 DOI: 10.1161/strokeaha.112.679100] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Observational studies indicate that outpatient cardiac monitoring detects previously undiagnosed atrial fibrillation (AF) in 5% to 20% of patients with recent stroke. However, it remains unknown whether the yield of monitoring exceeds that of routine clinical follow-up. METHODS In a pilot trial, we randomly assigned 40 patients with cryptogenic ischemic stroke or high-risk transient ischemic attack to wear a Cardionet mobile cardiac outpatient telemetry monitor for 21 days or to receive routine follow-up alone. After thorough investigation, we excluded patients with documented AF or other apparent stroke pathogenesis. We contacted patients and their physicians at 3 months and at 1 year to ascertain any diagnoses of AF or recurrent stroke or transient ischemic attack. RESULTS The baseline characteristics of our cohort broadly matched those of previous observational studies of monitoring after stroke. In the monitoring group, patients wore monitors for 64% of the assigned days, and 25% of patients were not compliant at all with monitoring. No patient in either study arm received a diagnosis of AF. Cardiac monitoring revealed AF in zero patients (0%; 95% confidence interval, 0%-17%), brief episodes of atrial tachycardia in 2 patients (10%; 95% confidence interval, 1%-32%), and nonsustained ventricular tachycardia in 2 patients (10%; 95% confidence interval, 1%-32%). CONCLUSIONS In the first reported randomized trial of cardiac monitoring after cryptogenic stroke, the rate of AF detection was lower than expected, incidental arrhythmias were frequent, and compliance with monitoring was suboptimal. Our findings highlight the challenges of prospectively identifying stroke patients at risk for harboring paroxysmal AF and ensuring adequate compliance with cardiac monitoring. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00715533.
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Moftakhar P, English JD, Cooke DL, Kim WT, Stout C, Smith WS, Dowd CF, Higashida RT, Halbach VV, Hetts SW. Density of thrombus on admission CT predicts revascularization efficacy in large vessel occlusion acute ischemic stroke. Stroke 2012; 44:243-5. [PMID: 23111438 DOI: 10.1161/strokeaha.112.674127] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Can lysability of large vessel thrombi in acute ischemic stroke be predicted by measuring clot density on admission nonenhanced CT (NECT), postcontrast enhanced CT, or CT angiogram (CTA)? METHODS We retrospectively studied 90 patients with acute large vessel ischemic strokes treated with intravenous (IV) tPA, intra-arterial (IA) tPA, and/or mechanical thrombectomy devices. Clot density [in Hounsfield unit (HU)] was measured on NECT, postcontrast enhanced CT, and CTA. Recanalization was assessed by the Thrombolysis in Cerebral Infarction grading system (TICI) on digital subtraction angiography. RESULTS Thrombus density on preintervention NECT correlated with postintervention TICI grade regardless of pharmacological (IV tPA r=0.69, IA tPA r=0.72, P<0.0001) or mechanical treatment (r=0.73, P<0.0001). Patients with TICI≥2 demonstrated higher HU on NECT (mean corrected HU IV tPA=1.58, IA tPA=1.66, mechanical treatment=1.7) compared with patients with TICI<2 (IV tPA=1.39, IA tPA=1.4, mechanical treatment=1.3) (P=0.01, 0.006, <0.0001 respectively). There was no association between recanalization and age, sex, baseline National Institute of Health Stroke Scale, treatment method, time to treatment, or clot volume. CONCLUSIONS Thrombi with lower HU on NECT appear to be more resistant to pharmacological lysis and mechanical thrombectomy. Measuring thrombus density on admission NECT provides a rapid method to analyze clot composition, a potentially useful discriminator in selecting the most appropriate reperfusion strategy for an individual patient.
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Nahab F, Walker GA, Dion JE, Smith WS. Safety of Periprocedural Heparin in Acute Ischemic Stroke Endovascular Therapy: The Multi MERCI Trial. J Stroke Cerebrovasc Dis 2012; 21:790-3. [DOI: 10.1016/j.jstrokecerebrovasdis.2011.04.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 04/15/2011] [Indexed: 10/18/2022] Open
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Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012; 380:1231-40. [PMID: 22932714 PMCID: PMC4176618 DOI: 10.1016/s0140-6736(12)61299-9] [Citation(s) in RCA: 848] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Present mechanical devices are unable to achieve recanalisation in up to 20-40% of large vessel occlusion strokes. We compared efficacy and safety of the Trevo Retriever, a new stent-like device, with its US Food and Drug Administration-cleared predecessor, the Merci Retriever. METHODS In this open-label randomised controlled trial, we recruited patients at 26 sites in the USA and one in Spain. We included adults aged 18-85 years with angiographically confirmed large vessel occlusion strokes and US National Institutes of Health Stroke Scale (NIHSS) scores of 8-29 within 8 h of symptom onset. We randomly assigned patients (1:1) with sequentially numbered sealed envelopes to thrombectomy with Trevo or Merci devices. Randomisation was stratified by age (≤68 years vs 69-85 years) and NIHSS scores (≤18 vs 19-29) with alternating blocks of various sizes. The primary efficacy endpoint, assessed by an unmasked core laboratory, was thrombolysis in cerebral infarction (TICI) scores of 2 or greater reperfusion with the assigned device alone. The primary safety endpoint was a composite of procedure-related adverse events. Analyses were done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01270867. FINDINGS Between Feb 3, 2011, and Dec 1, 2011, we randomly assigned 88 patients to the Trevo Retriever group and 90 patients to Merci Retriever group. 76 (86%) patients in the Trevo group and 54 (60%) in the Merci group met the primary endpoint after the assigned device was used (odds ratio 4·22, 95% CI 1·92-9·69; p(superiority)<0·0001). Incidence of the primary safety endpoint did not differ between groups (13 [15%] patients in the Trevo group vs 21 [23%] in the Merci group; p=0·1826). INTERPRETATION Patients who have had large vessel occlusion strokes but are ineligible for (or refractory to) intravenous tissue plasminogen activator should be treated with the Trevo Retriever in preference to the Merci Retriever. FUNDING Stryker Neurovascular.
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Stein DM, Roddy V, Marx J, Smith WS, Weingart SD. Emergency Neurological Life Support: Traumatic Spine Injury. Neurocrit Care 2012; 17 Suppl 1:S102-11. [DOI: 10.1007/s12028-012-9759-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Flint AC, Kamel H, Rao VA, Cullen SP, Faigeles BS, Smith WS. Validation of the Totaled Health Risks in Vascular Events (THRIVE) Score for Outcome Prediction in Endovascular Stroke Treatment. Int J Stroke 2012; 9:32-9. [DOI: 10.1111/j.1747-4949.2012.00872.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background We recently developed the Totaled Health Risks In Vascular Events (THRIVE) score to predict outcomes after endovascular stroke treatment. The THRIVE score, which incorporates age, National Institutes of Health Stroke Scale score, and three medical comorbidities (hypertension, diabetes mellitus, and atrial fibrillation), was developed using data from the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi MERCI trials. Aims We set out to perform external validation of the THRIVE score using data from the largest registry of endovascular stroke treatment performed to date, the Merci Registry. Methods We compared the performance of the THRIVE score in two different data sets: the development cohort (the MERCI and Multi MERCI trials, n = 305) and a validation cohort (the Merci Registry, a prospective multicenter registry of patients undergoing endovascular stroke treatment, n = 1000). We examined the predictive utility of the THRIVE score across the range of clinical outcomes and used receiver–operator characteristics curve analysis to compare score performance in the two data sets. Results The THRIVE score predicted good outcome, death, and the full range of the modified Rankin Scale in a similar fashion between the MERCI trials and the Merci Registry. Receiver–operator characteristics curve comparisons showed no statistically significant difference in the performance of the THRIVE score between the two data sets: for good outcome, the receiver–operator characteristics area under the curve was 0.293 for the MERCI trials and 0.266 for the Merci Registry ( P = 0.47) and for death, the receiver–operator characteristics area under the curve was 0.692 for the MERCI trials and 0.717 for the Merci Registry ( P = 0.48). The THRIVE score and vessel recanalization were also found to be independent and unrelated predictors of clinical outcome. Conclusions The THRIVE score reliably predicts outcomes after endovascular stroke treatment and may be useful as a clinical prognostic tool and to perform severity adjustments in stroke clinical research.
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Smith WS, Weingart S. Emergency Neurological Life Support (ENLS): What to Do in the First Hour of a Neurological Emergency. Neurocrit Care 2012; 17 Suppl 1:S1-3. [DOI: 10.1007/s12028-012-9741-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nakagawa K, Smith WS. Evaluation and management of increased intracranial pressure. Continuum (Minneap Minn) 2012; 17:1077-93. [PMID: 22809983 DOI: 10.1212/01.con.0000407061.25284.28] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW : Persistent elevation of intracranial pressure (ICP) can lead to cerebral ischemia, brain herniation, and possibly death. Understanding the fundamental mechanism that contributes to the rise in ICP and recognizing the specific intracranial compartment involved (brain, CSF, or blood) can lead to early diagnosis and effective treatment. This article reviews the conceptual approach to a patient with elevated ICP. RECENT FINDINGS : The overall goal for patients with intracranial hypertension is to lower ICP below 20 mm Hg and to maintain cerebral perfusion pressure (CPP) between 60 mm Hg and 90 mm Hg to provide sufficient cerebral perfusion. Commonly used therapeutic interventions to lower ICP include decompressive surgery, osmotherapy, hyperventilation, barbiturate-induced metabolic suppression, and hypothermia; however, the selection of these interventions must be tailored to each patient by considering the particular diagnosis and intracranial pathophysiology. Emerging evidence suggests that cerebral autoregulation may fail at excessively high CPP (CPP greater than 100 mm Hg) as well as at low CPP (CPP less than 60 mm Hg) and that maximal cerebral autoregulation capacity may be achieved at an optimal CPP of 70 mm Hg to 90 mm Hg. SUMMARY : Increased ICP is a neurologic emergency that requires immediate intervention. However, the treatment itself is not without risk; thus, the risks and benefits of medical and surgical intervention must be carefully evaluated and individualized for each patient.
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Fields JD, Lutsep HL, Rymer MR, Budzik RF, Devlin TG, Baxter BW, Malek R, Padidar AM, Barnwell SL, Smith WS. Endovascular mechanical thrombectomy for the treatment of acute ischemic stroke due to arterial dissection. Interv Neuroradiol 2012; 18:74-9. [PMID: 22440604 DOI: 10.1177/159101991201800110] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Accepted: 11/19/2011] [Indexed: 11/17/2022] Open
Abstract
Arterial dissections account for 2% of strokes in all age groups, and up to 25% in patients aged 45 years or younger. The safety of endovascular intervention in this patient population is not well characterized. We identified all patients in the Merci registry - a prospective, multi-center post-market database enrolling patients treated with the Merci Retriever thrombectomy device - with arterial dissection as the most likely stroke etiology. Stroke presentation and procedural details were obtained prospectively; data regarding procedural complications, intracerebral hemorrhage (ICH), and the use of stenting of the dissected artery were obtained retrospectively. Of 980 patients in the registry, ten were identified with arterial dissection (8/10 ICA; 2/10 vertebrobasilar). The median age was 48 years with a baseline NIH stroke scale score of 16 and median time to treatment of 4.9 h. The procedure resulted in thrombolysis in cerebral ischemia (TICI) scores of 2a or better in eight out of ten and TICI 2b or better in six out of ten patients. Stenting of the dissection was performed in four of nine (44%). The single complication (1/9; 11%) - extension of a dissected carotid artery - was treated effectively with stenting. No symptomatic ICH or stroke in a previously unaffected territory occurred. A favorable functional outcome was observed in eight out of ten patients. Despite severe strokes on presentation, high rates of recanalization (8/10) and favorable functional outcomes (8/10) were observed. These results suggest that mechanical thrombectomy in patients with acute stroke resulting from arterial dissection is feasible, safe, and may be associated with favorable functional outcomes.
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Navi BB, Kamel H, McCulloch CE, Nakagawa K, Naravetla B, Moheet AM, Wong C, Johnston SC, Hemphill JC, Smith WS. Accuracy of Neurovascular Fellows' Prognostication of Outcome After Subarachnoid Hemorrhage. Stroke 2012; 43:702-7. [DOI: 10.1161/strokeaha.111.639161] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The purpose of this study was to determine the accuracy and optimal timing of physician prognostication in patients with subarachnoid hemorrhage, a prototypical neurological disease characterized by variable outcomes and frequent disability.
Methods—
From October 2009 to April 2010, treating neurologists at a tertiary care academic medical center made daily predictions of the modified Rankin Scale at 6 months for consecutive patients with subarachnoid hemorrhage. Actual functional outcomes at 6 months were determined by phone interview and dichotomized into good (modified Rankin Scale 0–2) and poor (modified Rankin Scale 3–6) outcomes. Descriptive statistics were used to assess the accuracy of prognostications. Multiple logistic regression and generalized estimating equations were used to assess changes in prognostication accuracy over time and the relationship between prognostication accuracy and clinical factors.
Results—
Physicians made 648 prognostications for 66 patients. Overall accuracy ranged from 78% to 88%. Among patients predicted to have a good outcome, 81% (95% CI, 71%–92%) actually had a good outcome, whereas 88% (95% CI, 77%–99%) of patients predicted to do poorly had poor outcomes. No significant trends were seen in prognostication accuracy over time during the hospital course (
P
=0.72). Increasing age, infection, mechanical ventilation, hydrocephalus, and seizures all significantly worsened physician accuracy.
Conclusions—
Neurologists were generally but not perfectly accurate in their prognostications of functional outcomes. The accuracy of prognoses did not correlate with the hospital day on which they were made but was affected by clinical factors that can cloud the neurological examination.
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Toossi S, Lomen-Hoerth C, Josephson SA, Gropper MA, Roberts J, Patton K, Smith WS. Organ donation after cardiac death in amyotrophic lateral sclerosis. Ann Neurol 2012; 71:154-6. [DOI: 10.1002/ana.22525] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 06/13/2011] [Accepted: 06/22/2011] [Indexed: 11/11/2022]
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