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Joundi RA, Smith EE, Ganesh A, Nogueira RG, McTaggart RA, Demchuk AM, Poppe AY, Rempel JL, Field TS, Dowlatshahi D, Sahlas J, Swartz R, Shah R, Sauvageau E, Puetz V, Silver FL, Campbell B, Chapot R, Tymianski M, Goyal M, Hill MD. Time From Hospital Arrival Until Endovascular Thrombectomy and Patient-Reported Outcomes in Acute Ischemic Stroke. JAMA Neurol 2024:2819393. [PMID: 38829660 PMCID: PMC11148789 DOI: 10.1001/jamaneurol.2024.1562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/29/2024] [Indexed: 06/05/2024]
Abstract
Importance The time-benefit association of endovascular thrombectomy (EVT) in ischemic stroke with patient-reported outcomes is unknown. Objective To assess the time-dependent association of EVT with self-reported quality of life in patients with acute ischemic stroke. Design, Setting, and Participants Data were used from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, which tested the effect of nerinetide on functional outcomes in patients with large vessel occlusion undergoing EVT and enrolled patients from March 1, 2017, to August 12, 2019. The ESCAPE-NA1 trial was an international randomized clinical trial that recruited patients from 7 countries. Patients with EuroQol 5-dimension 5-level (EQ-5D-5L) index values at 90 days and survivors with complete domain scores were included in the current study. Data were analyzed from July to September 2023. Exposure Hospital arrival to arterial puncture time and other time metrics. Main Outcomes and Measures EQ-5D-5L index scores were calculated at 90 days using country-specific value sets. The association between time from hospital arrival to EVT arterial-access (door-to-puncture) and EQ-5D-5L index score, quality-adjusted life years, and visual analog scale (EQ-VAS) were evaluated using quantile regression, adjusting for age, sex, stroke severity, stroke imaging, wake-up stroke, alteplase, and nerinetide treatment and accounting for clustering by site. Using logistic regression, the association between door-to-puncture time and reporting no or slight symptoms (compared with moderate, severe, or extreme problems) was determined in each domain (mobility, self-care, usual activities, pain or discomfort, and anxiety or depression) or across all domains. Time from stroke onset was also evaluated, and missing data were imputed in sensitivity analyses. Results Among 1105 patients in the ESCAPE-NA1 trial, there were 1043 patients with EQ-5D-5L index values at 90 days, among whom 147 had died and were given a score of 0, and 1039 patients (mean [SD] age, 69.0 [13.7] years; 527 male [50.7%]) in the final analysis as 4 did not receive EVT. There were 896 survivors with complete domain scores at 90 days. There was a strong association between door-to-puncture time and EQ-5D-5L index score (increase of 0.03; 95% CI, 0.02-0.04 per 15 minutes of earlier treatment), quality-adjusted life years (increase of 0.29; 95% CI, 0.08-0.49 per 15 minutes of earlier treatment), and EQ-VAS (increase of 1.65; 95% CI, 0.56-2.72 per 15 minutes of earlier treatment). Each 15 minutes of faster door-to-puncture time was associated with higher probability of no or slight problems in each of 5 domains and all domains concurrently (range from 1.86%; 95% CI, 1.14-2.58 for pain or discomfort to 3.55%; 95% CI, 2.06-5.04 for all domains concurrently). Door-to-puncture time less than 60 minutes was associated higher odds of no or slight problems in each domain, ranging from odds ratios of 1.49 (95% CI, 1.13-1.95) for pain or discomfort to 2.59 (95% CI, 1.83-3.68) for mobility, with numbers needed to treat ranging from 7 to 17. Results were similar after multiple imputation of missing data and attenuated when evaluating time from stroke onset. Conclusions and Relevance Results suggest that faster door-to-puncture EVT time was strongly associated with better health-related quality of life across all domains. These results support the beneficial impact of door-to-treatment speed on patient-reported outcomes and should encourage efforts to improve patient-centered care in acute stroke by optimizing in-hospital processes and workflows.
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Affiliation(s)
- Raed A. Joundi
- Division of Neurology, Department of Medicine, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raul G. Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ryan A. McTaggart
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Alexandre Y. Poppe
- Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - Jeremy L. Rempel
- Department of Radiology, University of Alberta Hospital, Edmonton, Canada
| | - Thalia S. Field
- Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dar Dowlatshahi
- Department of Neurology, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Jim Sahlas
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard Swartz
- Department of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ruchir Shah
- Department of Neurology, Erlanger Hospital, Chattanooga, Tennessee
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, Florida
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Frank L. Silver
- University Health Network, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Campbell
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - René Chapot
- Department of Neuroradiology, Alfred Krupp Krankenhaus Essen, Essen, Germany
| | | | - Mayank Goyal
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Michael D. Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
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Asim R, Azeem B, Dogar MEA, Khurram L. Comment on "Risk factors and prognosis of early neurological deterioration in patients with posterior circulation cerebral infarction". Clin Neurol Neurosurg 2024; 240:108243. [PMID: 38537327 DOI: 10.1016/j.clineuro.2024.108243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/11/2024] [Indexed: 04/29/2024]
Affiliation(s)
- Rabia Asim
- Medicine Department, Shaheed Mohtarma Benazir Bhutto Medical College Liyari, Karachi 75660, Pakistan.
| | - Bazil Azeem
- Medicine Department, Shaheed Mohtarma Benazir Bhutto Medical College Liyari, Karachi 75660, Pakistan.
| | - Mata-E-Alla Dogar
- Medicine Department, Shaheed Mohtarma Benazir Bhutto Medical College Liyari, Karachi 75660, Pakistan.
| | - Laiba Khurram
- Medicine Department, Shaheed Mohtarma Benazir Bhutto Medical College Liyari, Karachi 75660, Pakistan.
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Ademola A, Bala F, Menon BK, Thornton J, Casetta I, Nannoni S, Goyal M, Herlihy D, Fainardi E, Power S, Saia V, Hegarty A, Pracucci G, Demchuk A, Mangiafico S, Boyle K, Michel P, Hildebrand KA, Sajobi TT, Hill MD, Toni D, Murphy S, Kim BJ, Almekhlafi MA. Workflow and Outcome of Thrombectomy in Late Time Window: A Pooled Multicenter Analysis. Can J Neurol Sci 2024:1-7. [PMID: 38639107 DOI: 10.1017/cjn.2024.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND We investigated the impact of workflow times on the outcomes of patients treated with endovascular thrombectomy (EVT) in the late time window. METHODS Individual patients' data who underwent EVT in the late time window (onset to imaging >6 hours) were pooled from seven registries and randomized clinical trials. Multiple time intervals were analyzed. Mixed-effects logistic regression was used to estimate the likelihood of functional independence at 90 days (modified Rankin Scale 0-2). Mixed-effects negative binomial regression was used to evaluate the relationship between patient characteristics and workflow time intervals. RESULTS 608 patients were included. The median age was 70 years (IQR: 58-71), 307 (50.5%) were female, and 310 (53.2%) had wake-up strokes. Successful reperfusion was achieved in 493 (81.2%) patients, and 262 (44.9%) achieved 90-day mRS 0-2. The estimated odds of functional independence decreased by 13% for every 30 minute delay from emergency department (ED) arrival to imaging time and by 7% from ED arrival to the end of EVT in the entire cohort. Also, the estimated odds of functional independence decreased by 33% for every 30 minute delay in the interval from arterial puncture to end of EVT, 16% in the interval from arrival in ED to end of EVT and 6% in the interval from stroke onset to end of EVT among patients who had a wake-up stroke. CONCLUSION Faster workflow from ED arrival to end of EVT is associated with improved functional independence among stroke patients treated in the late window.
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Affiliation(s)
- Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - John Thornton
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ilaria Casetta
- Clinica Neurologica, University of Ferrara, Ferrara, Italy
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Darragh Herlihy
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Sarah Power
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Valentina Saia
- Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Aidan Hegarty
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | | | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | | | - Karl Boyle
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Kevin A Hildebrand
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Danilo Toni
- Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Mohammed A Almekhlafi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
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Zou Y, Tu J, Hu P, Zhao X, Tang X. The prognostic value of ASPECTS in specific regions following mechanical thrombectomy in patients with acute ischemic stroke from large-vessel occlusion. Front Neurol 2024; 15:1372778. [PMID: 38685947 PMCID: PMC11057371 DOI: 10.3389/fneur.2024.1372778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/25/2024] [Indexed: 05/02/2024] Open
Abstract
Objective The aim of this study is to investigate the relationship between the volume of specific regional infarction and the prognosis of patients who undergo mechanical thrombectomy (MT) for acute large vessel occlusion. Methods In this study, we collected the clinical and imaging features of patients with unilateral acute anterior circulation ischemic stroke from January 2021 to June 2023 in the Second Affiliated Hospital of Nanchang University. All patients underwent CT perfusion and non-contrast CT scan before MT. The ASPECTS was assessed based on imaging data, and artificial intelligence was used to obtain the percentage of infarction in each of the 10 regions of ASPECTS. According to the modified Rankin Scale, the patients were divided into the good prognosis group and poor prognosis group at the 90-day follow-up. Various indicators in the two groups were compared. Multivariable logistic regression was used to assess the risk factors for poor prognosis. The relationship between core infarction volume and the probability of poor prognosis was plotted to analyze the trend of poor prognosis with changes in the proportion of infarction volume. Finally, a receiver operating characteristic curve was constructed to analyze the predictive ability on poor prognosis. Results A total of 91 patients were included, with 58 patients having a good prognosis (mRS ≤ 2) and 33 patients having a poor prognosis (mRS ≥ 3). Multivariate analysis showed that NIHSS score and core infarction involving the internal capsule and M6 region were independent risk factors for poor prognosis. According to the linear correlation, a higher ratio of core infarction volume in the internal capsule or M6 region was linked to an increased risk of a poor prognosis. However, the non-linear analysis revealed that the prognostic impact of core infarction volume was significant when the ratio was greater than 69.7%. The ROC curve indicated that the combination of NIHSS score, infarct location, and the ratio of infarct volume has an AUC of 0.87, with a sensitivity of 84.8% and a specificity of 84.5%. Conclusion It is important to examine the location and volume of the infarct in the internal capsule and M6 when deciding whether to do a MT.
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Affiliation(s)
- Yu Zou
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Jianglong Tu
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Pengxin Hu
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Xiaoping Tang
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
- School of Medicine, National Graduate College for Engineers, Tsinghua University, Beijing, China
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Lam TJR, Liu Z, Tan BYQ, Ng YY, Tan CK, Wong XY, Venketasubramanian N, Yeo LLL, Ho AFW, Ong MEH. Prehospital stroke care in Singapore. Singapore Med J 2024:00077293-990000000-00102. [PMID: 38449072 DOI: 10.4103/singaporemedj.smj-2023-066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/03/2023] [Indexed: 03/08/2024]
Abstract
ABSTRACT Due to the narrow window of opportunity for stroke therapeutics to be employed, effectiveness of stroke care systems is predicated on the efficiency of prehospital stroke systems. A robust prehospital stroke system of care that provides a rapid and well-coordinated response maximises favourable poststroke outcomes, but achieving this presents a unique set of challenges dependent on demographic and geographical circumstances. Set in the context of a highly urbanised first-world nation with a rising burden of stroke, Singapore's prehospital stroke system has evolved to reflect the environment in which it operates. This review aims to characterise the current state of prehospital stroke care in Singapore, covering prehospital aspects of the stroke survival chain from symptom onset till arrival at the emergency department. We identify areas for improvement and innovation, as well as provide insights into the possible future of prehospital stroke care in Singapore.
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Affiliation(s)
| | - Zhenghong Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Yih Ying Ng
- Department of Preventive and Population Medicine, Tan Tock Seng Hospital, Singapore
- Ministry of Home Affairs, Singapore Civil Defence Force, Singapore
| | - Colin Kaihui Tan
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | - Xiang Yi Wong
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | | | | | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
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Bertalan G, Duparc R, Krepuska M, Toth D, Madjidyar J, Thurner P, Schubert T, Kulcsar Z. Dynamic Perviousness Predicts Revascularization Success in Acute Ischemic Stroke. Diagnostics (Basel) 2024; 14:535. [PMID: 38473007 DOI: 10.3390/diagnostics14050535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND The predictive value of thrombus perviousness in acute ischemic stroke (AIS), as measured by computed tomography (CT), has been intensively studied with conflicting results. In this study, we investigate the predictive potential of the novel concept of dynamic perviousness using three-dimensional (3D) volumetric evaluation of occlusive thrombi. METHODS The full thrombus volume in 65 patients with a hyperdense artery sign on non-contrast CT (NCCT), who underwent mechanical thrombectomy (MT), was segmented. Perviousness maps were computed voxel-wise for the entire thrombus volume as thrombus attenuation increase (TAI) between NCCT and CT angiography (CTA) as well as between CTA and late venous phase CT (CTV). Perviousness was analyzed for its association with NIHSS at admission, Thrombolysis In Cerebral Infarction (TICI) score, and number of MT passes. RESULTS The mean late-uptake TAI of thrombi with NIHSS scores greater than 21 at admission was approximately 100% higher than for lower scored NIHSS (p between 0.05 and 0.005). Concerning revascularization results, thrombi requiring less than four MT passes had ca. 80% higher group mean late-uptake TAI than clots requiring four or more passes (p = 0.03), and thrombi with TICI score III had ca. 95% higher group mean late-uptake TAI than thrombi with TICI II (p = 0.03). Standard perviousness showed no significant correlation with MT results. CONCLUSION Standard thrombus perviousness of 3D clot volume is not associated with revascularization results in AIS. In contrast, dynamic perviousness assessed with a voxel-wise characterization of 3D thrombi volume may be a better predictor of MT outcomes than standard perviousness.
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Affiliation(s)
- Gergely Bertalan
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Roxane Duparc
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Miklos Krepuska
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Daniel Toth
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Jawid Madjidyar
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
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Sun B, Luo J, Li Z, Chen D, Wang Q, Si W. Muscone alleviates neuronal injury via increasing stress granules formation and reducing apoptosis in acute ischemic stroke. Exp Neurol 2024; 373:114678. [PMID: 38185313 DOI: 10.1016/j.expneurol.2024.114678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/10/2023] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
As the main bioactive component of musk, muscone has been reported to have marked protective effects in treating acute ischemic stroke (AIS). However, the specific anti-stroke mechanism of muscone still needs further research. In the current investigation, the PC12 cells OGD/R and the rat transient MCAO/R models were utilized as the AIS models. Serum hepatic and renal functional indexes (ALT, AST, BUN, and Cr) and cell viability were determined to select the appropriate muscone concentrations for in vitro and in vivo experiments. TTC, Hematoxylin and eosin (H&E), and Live/Dead staining were utilized to evaluate the protective effects of muscone in injured tissues and cells. Western blotting analysis, TUNEL staining, propidium iodide, and annexin V staining were applied to detect the anti-apoptotic effect of muscone. Double-label immunofluorescence staining of T-cell intracellular antigen-1 (TIA1) and Ras-GAP SH3 domain-binding protein 1 (G3BP1) was performed to observe whether muscone regulated the SG formation level. Molecular docking, TIA1 silencing and TIA1 overexpression experiments were employed to investigate the molecular mechanism underlying the regulation of SG formation by muscone. The 2, 3, 5-Triphenyl-tetrazolium chloride (TTC) staining and live/dead staining showed the AIS injury level of MCAO/R rat and the OGD/R PC12 cells were attenuated by muscone administration. The muscone significantly minimized the apoptosis rate in MCAO/R rats and OGD/R PC12 cells following flow cytometry analysis, western blotting analysis, and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining. The double-label immunofluorescence staining data revealed that muscone promoted the SG formation level in OGD/R PC12 cells and the cortex MCAO/R rats. The results of molecular docking, TIA1 silencing and TIA1 overexpression experiments revealed that muscone could bind to TIA1 protein and regulate its expression level, thereby promoting the formation of stress granules and exerting a protective effect against AIS injury. This study indicated that the significant protective effect of muscone in reducing apoptosis levels might be via promoting SG formation under AIS conditions. This study further explores the therapeutic effect and anti-apoptosis mechanism of muscone in AIS, which may provide a potential candidate drug for the clinical treatment of AIS injury.
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Affiliation(s)
- Bin Sun
- School of Integrated Chinese and Western Medicine, Anhui University of Chinese Medicine, Hefei, Anhui 230012, PR China
| | - Jing Luo
- School of Integrated Chinese and Western Medicine, Anhui University of Chinese Medicine, Hefei, Anhui 230012, PR China
| | - Zhen Li
- Department of Neurology, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Shenzhen, Guangdong 518104, PR China
| | - Dongfeng Chen
- Department of Anatomy, The Research Center of Basic Integrative Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510006, PR China
| | - Qizhang Wang
- Department of Neurology, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Shenzhen, Guangdong 518104, PR China
| | - Wenwen Si
- School of Integrated Chinese and Western Medicine, Anhui University of Chinese Medicine, Hefei, Anhui 230012, PR China.
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Wang W, Xu Y, Zhang B, Liu S, Ma Z, Wang S, Zhang P, Wei M. Mechanical thrombectomy using the retrograde semi-retrieval technique for patients with underlying intracranial atherosclerotic stenosis. Front Neurol 2024; 14:1280181. [PMID: 38283684 PMCID: PMC10811598 DOI: 10.3389/fneur.2023.1280181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/13/2023] [Indexed: 01/30/2024] Open
Abstract
Background The retrograde semi-retrieval technique (RESET) has been described as a modified technique for endovascular thrombectomy (EVT) whose safety and efficacy for intracranial atherosclerosis stenosis (ICAS) patients remain uncertain. This article presents our single-center experience, comparing RESET vs. non-RESET in ICAS patients. Materials and methods We analyzed 327 consecutive ICAS patients who underwent EVT at Tianjin Huanhu Hospital from January 2018 and December 2022. Patients were categorized into two groups: RESET and non-RESET. The primary outcome was the first-pass effect (FPE). Secondary outcomes included successful reperfusion, functional independence at 90 days, mortality, and symptomatic intracranial hemorrhage (sICH). Results RESET was significantly associated with FPE [adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.03-3.87, p = 0.040]. RESET was not significantly associated with successful reperfusion (aOR 1.5, CI 0.55-4.06, p = 0.425), an mRS of 0-2 at 90 days (aOR 1.36, CI 0.83-2.21, p = 0.223), sICH (aOR 0.39, CI 0.12-1.23, p = 0.108), and mortality (aOR 0.49, CI 0.16-1.44, p = 0.193). After propensity score matching, the results were consistent with the primary analysis. Conclusion Compared to non-RESET, patients treated with RESET showed increased FPE incidence and significantly decreased puncture-to-reperfusion time. RESET was proven to be safe and effective in enhancing reperfusion for LVO patients receiving EVT with underlying ICAS.
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Affiliation(s)
- Wei Wang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
- Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin, China
| | - Yongbo Xu
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Bohao Zhang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
- Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin, China
| | - Shuling Liu
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Zhenjian Ma
- Department of Neurosurgery, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Sifei Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Pinyuan Zhang
- Department of Neurosurgery (Cerebrovascular Disease), The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ming Wei
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
- Department of Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
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9
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Xu R, Nair SK, Kilgore CB, Xie ME, Jackson CM, Hui F, Gailloud P, McDougall CG, Gonzalez LF, Huang J, Tamargo RJ, Caplan J. Hypothermia is Associated with Improved Neurological Outcomes After Mechanical Thrombectomy. World Neurosurg 2024; 181:e126-e132. [PMID: 37690581 PMCID: PMC11060169 DOI: 10.1016/j.wneu.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is the second leading cause of death globally. Mechanical thrombectomy (MT) has improved patient prognosis but expedient treatment is still necessary to minimize anoxic injury. Lower intraoperative body temperature decreases cerebral oxygen demand, but the role of hypothermia in treatment of AIS with MT is unclear. METHODS We retrospectively reviewed patients undergoing MT for AIS from 2014 to 2020 at our institution. Patient demographics, comorbidities, intraoperative parameters, and outcomes were collected. Maximum body temperature was extracted from minute-by-minute anesthesia readings, and patients with maximal temperature below 36°C were considered hypothermic. Risk factors were assessed by χ2 and multivariate ordinal regression. RESULTS Of 68 patients, 27 (40%) were hypothermic. There was no significant association of hypothermia with patient age, comorbidities, time since last known well, number of passes intraoperatively, favorable revascularization, tissue plasminogen activator use, and immediate postoperative complications. Hypothermic patients exhibited better neurologic outcome at 3-month follow-up (P = 0.02). On multivariate ordinal regression, lower maximum intraoperative body temperature was associated with improved 3-month outcomes (P < 0.001), when adjusting for other factors influencing neurological outcomes. Other significant protective factors included younger age (P = 0.03), better revascularization (P = 0.03), and conscious sedation (P = 0.02). CONCLUSIONS Lower intraoperative body temperature during MT was independently associated with improved neurological outcome in this single center retrospective series. These results may help guide clinicians in employing therapeutic hypothermia during MT to improve long-term neurologic outcomes from AIS, although larger studies are needed.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Collin B Kilgore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael E Xie
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ferdinand Hui
- Division of Neurointerventional Surgery, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Phillipe Gailloud
- Department of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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10
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Lee IH, Choi JI, Ha SK, Lim DJ. Predictive Factors of First-Pass Effect in Patients Who Underwent Successful Endovascular Thrombectomy for Emergent Large Vessel Occlusion. J Korean Neurosurg Soc 2024; 67:14-21. [PMID: 37424093 PMCID: PMC10788560 DOI: 10.3340/jkns.2023.0072] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/26/2023] [Accepted: 07/05/2023] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE The primary treatment goal of current endovascular thrombectomy (EVT) for emergent large-vessel occlusion (ELVO) is complete recanalization after a single maneuver, referred to as the 'first-pass effect' (FPE). Hence, we aimed to identify the predictive factors of FPE and assess its effect on clinical outcomes in patients with ELVO of the anterior circulation. METHODS Among the 129 patients who participated, 110 eligible patients with proximal ELVO (intracranial internal carotid artery and proximal middle cerebral artery) who achieved successful recanalization after EVT were retrospectively reviewed. A comparative analysis between patients who achieved FPE and all others (defined as a non-FPE group) was performed regarding baseline characteristics, clinical variables, and clinical outcomes. Multivariate logistic regression analyses were subsequently conducted for potential predictive factors with p<0.10 in the univariate analysis to determine the independent predictive factors of FPE. RESULTS FPE was achieved in 31 of the 110 patients (28.2%). The FPE group had a significantly higher level of functional independence at 90 days than did the non-FPE group (80.6% vs. 50.6%, p=0.002). Pretreatment intravenous thrombolysis (IVT) (odds ratio [OR], 3.179; 95% confidence interval [CI], 1.025-9.861; p=0.045), door-to-puncture (DTP) interval (OR, 0.959; 95% CI, 0.932-0.987; p=0.004), and the use of balloon guiding catheter (BGC) (OR, 3.591; 95% CI, 1.231-10.469; p=0.019) were independent predictive factors of FPE. CONCLUSION In conclusion, pretreatment IVT, use of BGC, and a shorter DTP interval were positively associated with FPE, increasing the chance of acquiring better clinical outcomes.
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Affiliation(s)
- In-Hyoung Lee
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jong-Il Choi
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Sung-Kon Ha
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Dong-Jun Lim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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11
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Parvathy G, Dey RC, Kutikuppala LVS, Maheshwari AR, Josey E, Chintala JS, Abdullah M, Godugu S. Mechanical thrombectomy for AIS from large vessel occlusion - current trends and future perspectives. Ann Med Surg (Lond) 2023; 85:6021-6028. [PMID: 38098569 PMCID: PMC10718368 DOI: 10.1097/ms9.0000000000001385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/28/2023] [Indexed: 12/17/2023] Open
Abstract
Stroke is found to be one of the global top causes of mortality and the major factor in years of life with a handicap (DALYs). Ischemic strokes contributed to nearly 70% of all strokes worldwide. For endovascular thrombectomy in acute ischemic stroke with large vessel obstruction (AIS-LVO), using stent retrievers and/or reperfusion catheters has become the gold standard of therapy. The methodology involved keyword-based search in databases like PubMed, Embase, and Google Scholar for recent publications on mechanical thrombectomy (MT), AIS, large vessel occlusion (Large Vessel Occlusion (LVO)), screening relevant articles, retrieving full texts, and synthesizing key findings on procedural advancements, patient selection, COVID-19 (coronavirus disease 2019) impact, delay effects, effectiveness, clinical outcomes, and future perspectives. Only people with substantial cerebral artery obstruction may do well from MT. This includes the distal carotid artery and the proximal middle cerebral artery (segment M1). The size of a blocked vessel and NIHSS (National Institute of Health Stroke Scale) score are directly connected. Both the 2018 and 2019 versions of the AHA/ASA (American Heart Association/American Stroke Association) Guidelines for the Early Management of Patients with Acute Ischemic Stroke contained the recommendations that cases with AIS-LVO get endovascular therapy when administered during the time frame of 0-6 h after onset (Grade IA evidence). It is questionable whether this group of patients can be managed without the need for intravenous tissue plasminogen activator at the onset. When functional independence [modified Rankin Scale (mRS) score 2] was present at long-term follow-up, the endovascular intervention was favored. Tenecteplase, which differs from alteplase in terms of genetic variation, has a greater half-life and a higher level of fibrin selectivity, enabling bolus infusion. Studies have also demonstrated its efficacy and safety, as well as its long-term cost-effectiveness.
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Affiliation(s)
- Gauri Parvathy
- Department of Internal Medicine, Tbilisi State Medical University, Tbilisi, Georgia
| | - Rohit C. Dey
- Department of Internal Medicine, Altai State Medical University, Barnaul, Russia
| | | | - Aakansh R. Maheshwari
- Department of Internal Medicine, Pacific Medical College and Hospital, Rajasthan, India
| | - Elwy Josey
- Department of Internal Medicine, Dubai Academic Health Corporation
| | - Jyothi S. Chintala
- Department of Anesthesiology, Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Chinaoutpalli, Andhra Pradesh
| | | | - Swathi Godugu
- Department of Internal Medicine, Zaporozhye State Medical University, Zaporozhye, Ukraine
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12
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Rong B, Guo Z, Gao L, Yang Y, Zi W, Qiu Z, Li F, Lv Z, Luo Y, Meng R, Xie Y, Long T, Zhang S, Jiang J, Tian J, Zhao J, Zeng H, Yuan Z. Association of tirofiban treatment with outcomes following endovascular therapy in cardioembolic stroke: insights from the RESCUE BT randomized trial. Eur J Med Res 2023; 28:473. [PMID: 37915101 PMCID: PMC10621173 DOI: 10.1186/s40001-023-01406-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/28/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND AND PURPOSE The efficacy and safety of tirofiban in endovascular therapy for cardioembolic ischemic stroke patients remain controversial. This study aimed to evaluate the role of intravenous tirofiban before endovascular therapy in cardioembolic stroke. METHODS This post hoc analysis utilized data from the RESCUE BT (Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke) trial, which was an investigator-initiated, randomized, double-blind, placebo-controlled trial. Participants were randomized to receive either tirofiban or a placebo in a 1:1 ratio before undergoing endovascular therapy. The study included patients aged 18 years or older, presenting with occlusion of the internal carotid artery or middle cerebral artery (MCA) M1/M2 within 24 h of the last known well time, and with a stroke etiology of cardioembolism. The primary efficacy outcome was global disability at 90 days, assessed using the modified Rankin Scale (mRS). The safety outcome included symptomatic intracranial hemorrhage (sICH) within 48 h and mortality within 90 days. RESULTS A total of 406 cardioembolic stroke patients were included in this study, with 212 assigned to the tirofiban group and 194 assigned to the placebo group. Tirofiban treatment did not correlate with a favorable shift towards a lower 90-day mRS score (adjusted common odds ratio [OR], 0.91; 95% CI 0.64-1.3; p = 0.617). However, the tirofiban group had a significantly higher risk of symptomatic intracranial hemorrhage (sICH) within 48 h (adjusted OR, 3.26; 95% CI 1.4-7.57; p = 0.006) compared to the placebo group. The adjusted odds ratio (aOR) for mortality within 90 days was 1.48 (95% CI 0.88-2.52; p = 0.143). CONCLUSIONS Tirofiban treatment was not associated with a lower level of disability and increased the incidence of sICH after endovascular therapy in cardioembolic stroke patients.
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Affiliation(s)
- Benbing Rong
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zhangbao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Lijie Gao
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yuan Yang
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, The 903Rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhiyu Lv
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ying Luo
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Renliang Meng
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yang Xie
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ting Long
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shujiang Zhang
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jinshan Jiang
- School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Jinfeng Tian
- School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Jingling Zhao
- School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Hongliang Zeng
- Department of Neurology, Ganzhou People's Hospital, Zhanggong District, 17 Hongqi Avenue, Ganzhou, China.
| | - Zhengzhou Yuan
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China.
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13
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Martinez-Gutierrez JC, Kim Y, Salazar-Marioni S, Tariq MB, Abdelkhaleq R, Niktabe A, Ballekere AN, Iyyangar AS, Le M, Azeem H, Miller CC, Tyson JE, Shaw S, Smith P, Cowan M, Gonzales I, McCullough LD, Barreto AD, Giancardo L, Sheth SA. Automated Large Vessel Occlusion Detection Software and Thrombectomy Treatment Times: A Cluster Randomized Clinical Trial. JAMA Neurol 2023; 80:1182-1190. [PMID: 37721738 PMCID: PMC10507590 DOI: 10.1001/jamaneurol.2023.3206] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/21/2023] [Indexed: 09/19/2023]
Abstract
Importance The benefit of endovascular stroke therapy (EVT) in large vessel occlusion (LVO) ischemic stroke is highly time dependent. Process improvements to accelerate in-hospital workflows are critical. Objective To determine whether automated computed tomography (CT) angiogram interpretation coupled with secure group messaging can improve in-hospital EVT workflows. Design, Setting, and Participants This cluster randomized stepped-wedge clinical trial took place from January 1, 2021, through February 27, 2022, at 4 comprehensive stroke centers (CSCs) in the greater Houston, Texas, area. All 443 participants with LVO stroke who presented through the emergency department were treated with EVT at the 4 CSCs. Exclusion criteria included patients presenting as transfers from an outside hospital (n = 158), in-hospital stroke (n = 39), and patients treated with EVT through randomization in a large core clinical trial (n = 3). Intervention Artificial intelligence (AI)-enabled automated LVO detection from CT angiogram coupled with secure messaging was activated at the 4 CSCs in a random-stepped fashion. Once activated, clinicians and radiologists received real-time alerts to their mobile phones notifying them of possible LVO within minutes of CT imaging completion. Main Outcomes and Measures Primary outcome was the effect of AI-enabled LVO detection on door-to-groin (DTG) time and was measured using a mixed-effects linear regression model, which included a random effect for cluster (CSC) and a fixed effect for exposure status (pre-AI vs post-AI). Secondary outcomes included time from hospital arrival to intravenous tissue plasminogen activator (IV tPA) bolus in eligible patients, time from initiation of CT scan to start of EVT, and hospital length of stay. In exploratory analysis, the study team evaluated the impact of AI implementation on 90-day modified Rankin Scale disability outcomes. Results Among 243 patients who met inclusion criteria, 140 were treated during the unexposed period and 103 during the exposed period. Median age for the complete cohort was 70 (IQR, 58-79) years and 122 were female (50%). Median National Institutes of Health Stroke Scale score at presentation was 17 (IQR, 11-22) and the median DTG preexposure was 100 (IQR, 81-116) minutes. In mixed-effects linear regression, implementation of the AI algorithm was associated with a reduction in DTG time by 11.2 minutes (95% CI, -18.22 to -4.2). Time from CT scan initiation to EVT start fell by 9.8 minutes (95% CI, -16.9 to -2.6). There were no differences in IV tPA treatment times nor hospital length of stay. In multivariable logistic regression adjusted for age, National Institutes of Health Stroke scale score, and the Alberta Stroke Program Early CT Score, there was no difference in likelihood of functional independence (modified Rankin Scale score, 0-2; odds ratio, 1.3; 95% CI, 0.42-4.0). Conclusions and Relevance Automated LVO detection coupled with secure mobile phone application-based communication improved in-hospital acute ischemic stroke workflows. Software implementation was associated with clinically meaningful reductions in EVT treatment times. Trial Registration ClinicalTrials.gov Identifier: NCT05838456.
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Affiliation(s)
| | - Youngran Kim
- Center for Healthcare Data, School of Public Health, UTHealth, Houston, Texas
| | | | | | - Rania Abdelkhaleq
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Arash Niktabe
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Anjan N. Ballekere
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Ananya S. Iyyangar
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Mai Le
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Hussain Azeem
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Charles C. Miller
- Department of Cardiovascular and Thoracic Surgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Jon E. Tyson
- Department of Pediatrics, McGovern Medical School at UTHealth Houston, Texas
| | - Sandi Shaw
- Memorial Herman Hospital, Houston, Texas
| | - Peri Smith
- Memorial Herman Hospital, Houston, Texas
| | | | | | | | - Andrew D. Barreto
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | - Luca Giancardo
- UTHealth School of Biomedical Informatics, Houston, Texas
| | - Sunil A. Sheth
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
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14
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Cancelliere NM, van Nijnatten F, Hummel E, Withagen P, van de Haar P, Nishi H, Agid R, Nicholson P, Hallacoglu B, van Vlimmeren M, Pereira VM. Motion artifact correction for cone beam CT stroke imaging: a prospective series. J Neurointerv Surg 2023; 15:e223-e228. [PMID: 36564201 DOI: 10.1136/jnis-2021-018201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 06/28/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Imaging assessment for acute ischemic stroke (AIS) patients in the angiosuite using cone beam CT (CBCT) has created increased interest since endovascular treatment became the first line therapy for proximal vessel occlusions. One of the main challenges of CBCT imaging in AIS patients is degraded image quality due to motion artifacts. This study aims to evaluate the prevalence of motion artifacts in CBCT stroke imaging and the effectiveness of a novel motion artifact correction algorithm for image quality improvement. METHODS Patients presenting with acute stroke symptoms and considered for endovascular treatment were included in the study. CBCT scans were performed using the angiosuite X-ray system. All CBCT scans were post-processed using a motion artifact correction algorithm. Motion artifacts were scored before and after processing using a 4-point scale. RESULTS We prospectively included 310 CBCT scans from acute stroke patients. 51% (n=159/310) of scans had motion artifacts, with 24% being moderate to severe. The post-processing algorithm improved motion artifacts in 91% of scans with motion (n=144/159), restoring clinical diagnostic capability in 34%. Overall, 76% of the scans were sufficient for clinical decision-making before correction, which improved to 93% (n=289/310) after post-processing with our algorithm. CONCLUSIONS Our results demonstrate that CBCT motion artifacts are significantly reduced using a novel post-processing algorithm, which improved brain CBCT image quality and diagnostic assessment for stroke. This is an important step on the road towards a direct-to-angio approach for endovascular thrombectomy (EVT) treatment.
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Affiliation(s)
- Nicole M Cancelliere
- Department of Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
- RADIS lab, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada
| | - Fred van Nijnatten
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | - Eric Hummel
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | - Paul Withagen
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | - Peter van de Haar
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | - Hidehisa Nishi
- RADIS lab, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ronit Agid
- Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Bertan Hallacoglu
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | | | - Vitor M Pereira
- Department of Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
- RADIS lab, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada
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15
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Van Orden K, Meyer DM, Perrinez ES, Torres D, Poynor B, Alwood B, Bykowski J, Khalessi A, Meyer BC. (VISIION-S): Viz.ai Implementation of Stroke augmented Intelligence and communications platform to improve Indicators and Outcomes for a comprehensive stroke center and Network - Sustainability. J Stroke Cerebrovasc Dis 2023; 32:107303. [PMID: 37572556 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107303] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/14/2023] Open
Abstract
OBJECTIVES As Comprehensive Stroke Centers (CSCs) strive to improve neuro-intervention (NIR) times, process improvements are put in place to streamline workflows. Our prior publication (VISIION) demonstrated improvements in key performance indicators (KPIs). The purpose VISIION-S was to analyze whether those results were sustainable. MATERIALS AND METHODS Consecutive Direct Arriving LVO (DALVO) and telemedicine transfer LVO (BEMI) stroke NIR cases were assessed, including subgroups of DALVO-OnHours, DALVO-OffHours, BEMI-OnHours, and BEMI-OffHours. We analyzed times for the original 6 months pre (6/10/20-1/15/21) and compared them to a 17 month post-implementation period (1/16/21- 6/25/22) to evaluate for sustainability. Mann-Whitney U was utilized. RESULTS 150 NIR cases were analyzed pre (n = 47) v. post (n = 103) implementation (DALVO-OnHours 7 v. 20, DALVO-OffHours 10 v. 25, BEMI-OnHours 13 v. 20, BEMI-OffHours 17 v. 38). For Door-to-groin (DTG), improvement was noted for DALVO-OffHours 39%(157 min,96 min;p < 0.001), DALVO-ALL 25%(127 min,95 min;p = 0.006), BEMI-OffHours 46%(45 min,25 min;p = 0.023), and BEMI-ALL 40%(42 min,25 min;p = 0.005). Activation-to-groin (ATG), door-to-device (DTD), and door-to-recanalization (DTR) also showed statistical improvements. For DALVO-OffHours, there were reductions in door to CT (DTC) 80%(26 min,5 min;p < 0.001), ATG 32%(90 min,61 min;p = 0.036), DTG 39%(157 min,96 min;p < 0.001), DTD 31%(178 min,123 min;p = 0.002), and DTR 32%(197 min,135 min;p = 0.003). CONCLUSIONS We noted sustainability over a 17 month period with sustained reduction in KPIs for even more NIR time interval comparisons. In the greatest opportunity subgroup (DALVO-OffHours), we noted a reduction in all 5 time interval metrics. Our sustainability finding is important to show that process improvements continued even after the immediate period, adding credibility to the results. Models such as this could be useful for other centers striving to optimize workflow and improve times.
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Affiliation(s)
- Kim Van Orden
- Department of Neurosciences, University of California, San Diego, California, USA.
| | - Dawn Matherne Meyer
- Department of Neurosciences, University of California, San Diego, California, USA.
| | - Emily S Perrinez
- Department of Neurosciences, University of California, San Diego, California, USA.
| | - Dolores Torres
- Department of Neurosciences, University of California, San Diego, California, USA.
| | - Briana Poynor
- Department of Neurosciences, University of California, San Diego, California, USA.
| | - Ben Alwood
- Department of Neurosciences, University of California, San Diego, California, USA.
| | - Julie Bykowski
- Department of Neurosciences, University of California, San Diego, California, USA.
| | - Alex Khalessi
- Department of Neurosciences, University of California, San Diego, California, USA.
| | - Brett C Meyer
- Department of Neurosciences, University of California, San Diego, California, USA.
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16
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Zhang M, Xing P, Tang J, Shi L, Yang P, Zhang Y, Zhang L, Peng Y, Liu S, Zhang L, Fu J, Liu J. Predictors and outcome of early neurological deterioration after endovascular thrombectomy: a secondary analysis of the DIRECT-MT trial. J Neurointerv Surg 2023; 15:e9-e16. [PMID: 35688618 DOI: 10.1136/neurintsurg-2022-018976] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is uncertainty regarding the predictors of early neurological deterioration (END) after endovascular thrombectomy in patients with acute ischemic stroke (AIS). Limited studies have focused on the effect of END on functional outcome. Our aim was to determine the predictors of END after endovascular thrombectomy in AIS and its effect on functional outcome at 90 days. METHODS This is a secondary analysis of the DIRECT-MT trial. Patients who failed to complete endovascular thrombectomy were additionally excluded. END was defined as ≥4-point increase in National Institutes of Health Stroke Scale score between admission and 24 hours after endovascular thrombectomy. Multivariable logistic regression was used to identify predictors for END and its effect on the modified Rankin Scale (mRS) score at 90 days. RESULTS Of 591 patients enrolled, 111 (18.8%) had postoperative END, which was associated with higher ordinal mRS score at 90 days (adjusted common OR (aOR) 6.968, 95% CI 4.444 to 10.926). Non-modifiable factors included baseline Alberta Stroke Program Early CT Score (aOR 0.883, 95% CI 0.790 to 0.987), systolic blood pressure (aOR 1.017, 95% CI 1.006 to 1.028), glucose level (aOR 1.178, 95% CI 1.090 to 1.273), collateral status (aOR 0.238, 95% CI 0.093 to 0.608), occlusion site (aOR 0.496, 95% CI 0.290 to 0.851) and the presence of an anterior communicating artery (aOR 0.323, 95% CI 0.148 to 0.707). Admission-to-groin puncture time (aOR 1.010, 95% CI 1.003 to 1.017), general anesthesia (aOR 2.299, 95% CI 1.193 to 4.444), number of passes (aOR 1.561, 95% CI 1.243 to 1.961) and contrast extravasation (aOR 6.096, 95% CI 1.543 to 24.088) were modifiable predictors for END. CONCLUSIONS Postoperative END is associated with adverse functional outcome. Several non-modifiable and modifiable factors can predict END and support future treatment decision-making to improve the potential utility of endovascular thrombectomy. TRIAL REGISTRATION NUMBER DIRECT-MT ClinicalTrials.gov NCT03469206.
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Affiliation(s)
- Miaoyi Zhang
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Shanghai, China
| | - Jie Tang
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Langfeng Shi
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Shanghai, China
| | - Ya Peng
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, China
| | - Sheng Liu
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liyong Zhang
- Department of Vascular Neurosurgery, Liaocheng Brain Hospital, Liaocheng, China
| | - Jianhui Fu
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Shanghai, China
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17
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Xu W, Bao X, Jiang F, Chen F, Liu B, Yu F, He P. Factors influencing the prognosis of acute basilar artery occlusion patients treated endovascularly: the impact of treatment time window and preoperative symptoms. Front Neurol 2023; 14:1167442. [PMID: 37545731 PMCID: PMC10400006 DOI: 10.3389/fneur.2023.1167442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023] Open
Abstract
Objective The aim of this study was to examine the factors influencing the prognosis of patients diagnosed with acute basilar artery occlusion (BAO) who receive endovascular treatment. Our particular emphasis was on the predictive implications of the time window for treatment (from symptom onset to femoral artery puncture) and preoperative symptoms for prognosis. Methods A retrospective analysis of data collected from 51 BAO patients who received endovascular treatment at the Neurosurgery Department of Jinhua Central Hospital from April 2018 to October 2021 was undertaken. The data included immediate post-interventional recanalization rates and the 90-day clinical prognoses of the patients. We used the Modified Rankin Scale (mRs) to categorize patients into two prognosis groups: a favorable prognosis group (mRs score ≤2) and an unfavorable prognosis group (mRs score >2). Preoperative symptoms were gauged using the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores. A logistic regression analysis was conducted to identify risk factors affecting the prognosis of BAO patients following endovascular treatment. Results The procedure resulted in complete recanalization in all patients (100%). However, four patients (7.8%) passed away during the postoperative hospitalization period. The remaining 47 patients were followed up for 3 months. It was found that 15 patients (31.91%) had a favorable prognosis, while 32 (68.09%) had an unfavorable prognosis. It was generally observed that patients with an unfavorable prognosis had notably higher preoperative GCS and NIHSS scores (p < 0.05). Logistic regression analysis revealed that preoperative symptom severity, as indicated by NIHSS score, and treatment time window were significant prognostic risk factors for patients undergoing endovascular treatment for BAO (p < 0.05). Conclusion Endovascular intervention for BAO appears to be safe and effective, with greater likelihood of a favorable prognosis in patients treated within ≤6 h. The chances of favorable prognosis could potentially be linked to the severity of the patient's preoperative symptoms.
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18
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Rodriguez-Calienes A, Galecio-Castillo M, Vivanco-Suarez J, Mohamed GA, Toth G, Sarraj A, Pujara D, Chowdhury AA, Farooqui M, Ghannam M, Samaniego EA, Jovin TG, Ortega-Gutierrez S. Endovascular thrombectomy beyond 24 hours from last known well: a systematic review with meta-analysis. J Neurointerv Surg 2023:jnis-2023-020443. [PMID: 37355251 DOI: 10.1136/jnis-2023-020443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Different studies have demonstrated the benefit of endovascular treatment (EVT) up to 24 hours after acute ischemic stroke (AIS) onset. Recent cohort observational studies suggest that patients with large vessel occlusion AIS may benefit from EVT beyond 24 hours from the last known well (LKW) when adequately selected. We aimed to examine the safety and efficacy of EVT beyond 24 hours from LKW using a meta-analysis of all the literature available. METHODS A systematic search from inception to April 2023 was conducted for studies including AIS patients with EVT beyond 24 hours from LKW in Medline, Embase, Scopus, and Web of Science. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0-2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Data were pooled using a random-effects model. RESULTS Twelve studies with 894 patients were included. The rate of favorable functional outcome was 40% (95% CI 31% to 49%; I2=76%). The rate of successful reperfusion was 83% (95% CI 80% to 85%; I2=0%). The sICH rate was 7% (95% CI 5% to 9%; I2=0%) and the 90-day mortality rate was 28% (95% CI 24% to 33%; I2=0%). There was no significant difference in favorable outcomes (OR=0.69; 95% CI 0.41 to 1.14) and 90-day mortality (OR=1.35; 95% CI 0.90 to 2.00) among patients who underwent EVT <24 hours versus >24 hours. CONCLUSIONS EVT beyond 24 hours from LKW may achieve favorable clinical outcomes and high reperfusion rates, with acceptable intracranial hemorrhage rates in selected patients. Considering the current certainty of the evidence and heterogenous individual study results, larger prospective trials are warranted.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru
| | | | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ghada A Mohamed
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Deep Pujara
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Aj A Chowdhury
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Malik Ghannam
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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19
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Hoelter P, Lang S, Beuscher V, Kallmuenzer B, Manhart M, Schwab S, Doerfler A. Extended Multimodal Flat Detector CT Imaging in Acute Ischemic Stroke: A Pilot Study. J Digit Imaging 2023; 36:1198-1207. [PMID: 36650300 PMCID: PMC10287862 DOI: 10.1007/s10278-022-00699-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 01/19/2023] Open
Abstract
By using Flat detector computed tomography (FD-CT), a one-stop-shop approach in the diagnostic workup of acute ischemic stroke (AIS) might be achieved. Although information on upstream vessels is warranted, dedicated FD-CT protocols which include the imaging of the cervical vasculature are still lacking. We aimed to prospectively evaluate the implementation of a new multimodal FD-CT protocol including cervical vessel imaging in AIS patients. In total, 16 patients were included in this study. Eight patients with AIS due to large vessel occlusion (LVO) prospectively received a fully multimodal FD-CT imaging, including non-enhanced flat detector computed tomography (NE-FDCT), dynamic perfusion flat detector computed tomography (FD-CTP) and flat detector computed tomography angiography (FD-CTA) including cervical imaging. For comparison of time metrics and image quality, eight AIS patients, which received multimodal CT imaging, were included retrospectively. Although image quality of NE-FDCT and FD-CTA was rated slightly lower than NE-CT and CTA, all FD-CT datasets were of diagnostic quality. Intracerebral hemorrhage exclusion and LVO detection was reliably possible. Median door-to-image time was comparable for the FD-CT group and the control group (CT:30 min, IQR27-58; FD-CT:44.5 min, IQR31-55, p = 0.491). Door-to-groin-puncture time (CT:79.5 min, IQR65-90; FD-CT:59.5 min, IQR51-67; p = 0.016) and image-to-groin-puncture time (CT:44 min, IQR30-50; FD-CT:14 min, IQR12-18; p < 0.001) were significantly shorter, when patients were directly transferred to the angiosuite, where FD-CT took place. Our study indicates that using a new fully multimodal FD-CT approach including imaging of cervical vessels for first-line imaging in AIS patients is feasible and comparable to multimodal CT imaging with substantial potential to streamline the stroke workflow.
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Affiliation(s)
- Philip Hoelter
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen- Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Stefan Lang
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen- Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Vanessa Beuscher
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmuenzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Manhart
- Siemens Healthcare GmbH, Advanced Therapies, Siemensstr. 1, 91301, Forchheim, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen- Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
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20
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Ghozy S, Azzam AY, Kallmes KM, Matsoukas S, Fifi JT, Luijten SPR, van der Lugt A, Adusumilli G, Heit JJ, Kadirvel R, Kallmes DF. The diagnostic performance of artificial intelligence algorithms for identifying M2 segment middle cerebral artery occlusions: A systematic review and meta-analysis. J Neuroradiol 2023; 50:449-454. [PMID: 36773845 DOI: 10.1016/j.neurad.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Artificial intelligence (AI)-based algorithms have been developed to facilitate rapid and accurate computed tomography angiography (CTA) assessment in proximal large vessel occlusion (LVO) acute ischemic stroke, including internal carotid artery and M1 occlusions. In clinical practice, however, the detection of medium vessel occlusion (MeVO) represents an ongoing diagnostic challenge in which the added value of AI remains unclear. PURPOSE To assess the diagnostic performance of AI platforms for detecting M2 occlusions. METHODS Studies that report the diagnostic performance of AI-based detection of M2 occlusions were screened, and sensitivity and specificity data were extracted using the semi-automated AutoLit software (Nested Knowledge, MN) platform. STATA (version 16 IC; Stata Corporation, College Station, Texas, USA) was used to conduct all analyses. RESULTS Eight studies with a low risk of bias and significant heterogeneity were included in the quantitative and qualitative synthesis. The pooled estimates of sensitivity and specificity of AI platforms for M2 occlusion detection were 64% (95% CI, 53 to 74%) and 97% (95% CI, 84 to 100%), respectively. The area under the curve (AUC) in the SROC curve was 0.79 (95% CI, 0.74 to 0.83). CONCLUSION The current performance of the AI-based algorithm makes it more suitable as an adjunctive confirmatory tool rather than as an independent one for M2 occlusions. With the rapid development of such algorithms, it is anticipated that newer generations will likely perform much better.
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Affiliation(s)
- Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC program), Oxford University, Oxford, UK.
| | | | - Kevin M Kallmes
- Nested Knowledge, St. Paul MN, USA; Superior Medical Experts, St. Paul MN, USA
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sven P R Luijten
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Jeremy J Heit
- Departments of Neuroradiology and Neurosurgery, Stanford University, Palo Alto, CA, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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21
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Kobeissi H, Ghozy S, Adusumilli G, Kadirvel R, Brinjikji W, Rabinstein AA, Kallmes DF. Endovascular Therapy for Stroke Presenting Beyond 24 Hours: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e2311768. [PMID: 37140919 PMCID: PMC10160871 DOI: 10.1001/jamanetworkopen.2023.11768] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Importance Previous randomized clinical trials (RCTs) have supported the use of endovascular therapy (EVT) in late-window acute ischemic stroke (AIS; 6-24 hours). However, little is known about the use of EVT in very late-window AIS (>24 hours). Objective To examine outcomes following EVT for very late-window AIS. Data Sources A systematic review of the English language literature was conducted using Web of Science, Embase, Scopus, and PubMed to search for articles published from database inception until December 13, 2022. Study Selection This systematic review and meta-analysis included published studies regarding very late-window AIS treated with EVT. Multiple reviewers screened studies, and an extensive manual search of the references of included articles was performed to identify any missed articles. Of the 1754 initially retrieved studies, 7 published between 2018 and 2023 were ultimately included. Data Extraction and Synthesis Data were extracted independently by multiple authors and evaluated for consensus. Data were pooled using a random-effects model. This study is reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guideline, and the protocol was prospectively registered with PROSPERO. Main Outcomes and Measures The primary outcome of interest was functional independence, as assessed with 90-day modified Rankin Scale (mRS) scores (0-2). Secondary outcomes included thrombolysis in cerebral infarction (TICI) scores (2b-3 or 3), symptomatic intracranial hemorrhage (sICH), 90-day mortality, early neurological improvement (ENI), and early neurological deterioration (END). Frequencies and means were pooled with the corresponding 95% CIs. Results This review included 7 studies involving a total of 569 patients. The mean baseline National Institutes of Health Stroke Scale score was 13.6 (95% CI, 11.9-15.5), and the mean Alberta Stroke Program Early CT Score was 7.9 (95% CI, 7.2-8.7). The mean time from last known well and/or onset to puncture was 46.2 hours (95% CI, 32.4-65.9 hours). Frequencies for the primary and secondary outcomes were 32.0% (95% CI, 24.7%-40.2%) for functional independence (90-day mRS scores of 0-2) and 81.9% (95% CI, 78.5%-84.9%) for TICI scores of 2b to 3, 45.3% (95% CI, 36.6%-54.4%) for TICI scores of 3, 6.8% (95% CI, 4.3%-10.7%) for sICH, and 27.2% (95% CI, 22.9%-31.9%) for 90-day mortality. In addition, frequencies were 36.9% (95% CI, 26.4%-48.9%) for ENI and 14.3% (95% CI, 7.1%-26.7%) for END. Conclusions and Relevance In this review, EVT for very late-window AIS was associated with favorable frequencies of 90-day mRS scores of 0 to 2 and TICI scores of 2b to 3 and with low frequencies of 90-day mortality and sICH. These results suggest that EVT may be safe and associated with improved outcomes for very late-window AIS, although RCTs and prospective, comparative studies are needed to determine which patients may benefit from very late intervention.
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Affiliation(s)
- Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
- College of Medicine, Central Michigan University, Mount Pleasant
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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22
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Liu H, Zhang Y, Fan H, Wen C. Risk Factors and Functional Outcomes with Early Neurological Deterioration after Mechanical Thrombectomy for Acute Large Vessel Occlusion Stroke. J Neurol Surg B Skull Base 2023; 84:183-191. [PMID: 36895817 PMCID: PMC9991527 DOI: 10.1055/a-1762-0167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 02/03/2022] [Indexed: 10/19/2022] Open
Abstract
Early neurological deterioration (END) is associated with a poor survival after mechanical thrombectomy (MT) in acute ischemic stroke (AIS). To assess risk factors and functional outcomes of END after MT in patients, we analyzed data from 79 patients who received MT with large-vessel occlusion. END after MT in patients is defined as an increase of two points or more in the National Institute of Health Stroke Scale (NIHSS) score, compared with the best neurological status within 7 days. The mechanism of END can be classified into: AIS progression, sICH, and encephaledema. A total of 32 AIS patients (40.5%) had END after MT. Risk factors for END after MT included: history of oral antiplatelet and/or anticoagulation drugs before MT (OR = 9.56,95% CI = 1.02-89.57), higher NIHSS score when admitted to hospital (OR = 1.24, 95% CI = 1.04-1.48), under the subtype of atherosclerotic stroke (OR = 17.36, 95% CI = 1.51-199.56), ASITN/SIR< 2 (OR = 15.78, 95% CI = 1.65-151.26), and prolonged period from AIS onset to the first revascularization (OR = 1.01, 95% CI = 1.00-1.02). AIS patients who had END at early stages were more likely to experience poor outcomes (Modified Rankin Scale [mRS] >2) at 90 days after MT (OR = 6.829, 95% CI = 1.573-29.655). Thus, AIS patients who had experienced END at early stages were more likely to have poor outcomes (mRS >2) at 90 days after MT, and the risk factors of END were connected to the mechanism of END.
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Affiliation(s)
- Hongwei Liu
- Department of Neurology, Shanxi Medical University, Taiyuan Central Hospital, Shanxi Province, China
| | - Yi Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Haixia Fan
- Department of Neurology, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Chao Wen
- Department of Neurology, Shanxi Medical University, Taiyuan Central Hospital, Shanxi Province, China
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23
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Hong L, Ling Y, Zhang Y, Yang L, Li S, Liu X, Dong Q, Cheng X. Reperfusion measurements, treatment time, and outcomes in patients receiving endovascular treatment within 24 hours of last known well. CNS Neurosci Ther 2023; 29:1067-1074. [PMID: 36601659 PMCID: PMC10018078 DOI: 10.1111/cns.14080] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023] Open
Abstract
AIMS The aim of this study was to explore the interaction between reperfusion and treatment time on the outcomes of patients undergoing endovascular treatment presenting within 24 h of last known well, and to compare the predictive ability of different reperfusion measurements on outcomes. METHODS Eligible patients from a single-center cohort were enrolled in this study. Reperfusion was assessed using reperfusion index (decreased volume of hypoperfusion lesion compared with baseline) measured by repeated perfusion imaging, and modified treatment in cerebral ischemia score measured by digital subtraction angiography, respectively. The interactions between reperfusion measurements and treatment time on outcomes were explored using multivariate-adjusted logistic and linear regression models. The predictive abilities of reperfusion measurements on outcomes were compared using area under the receiver operating characteristic curve (ROC-AUC) and values of R-square. RESULTS Reperfusion index and treatment time had significant interactions on 3-month modified Rankin Scale (mRS) 0-2 and infarct growth (p for interaction <0.05). Although the AUCs were statistically similar (AUCs of mRS 0-2 prediction, mTICI≥2b:0.63, mTICI≥2c:0.59, reperfusion index≥0.5:0.66, reperfusion index ≥0.9:0.73, P value of any of the two AUCs >0.05), reperfusion index≥0.9 showed the highest R-square values in outcome prediction (R-square values of 3-month mRS 0-2 and infarct growth = 0.21) among all the reperfusion measurements. CONCLUSION Treatment time mitigated the effect of reperfusion on outcomes of patients receiving endovascular treatment within 24 h of last known well. Reperfusion index≥0.9 might serve as a better proxy of good outcomes compared with other reperfusion measurements.
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Affiliation(s)
- Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Yiran Zhang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Lumeng Yang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Siyuan Li
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Xinyu Liu
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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24
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Dhillon PS, Butt W, Podlasek A, McConachie N, Lenthall R, Nair S, Malik L, Bhogal P, Makalanda HLD, Spooner O, Krishnan K, Sprigg N, Mortimer A, Booth TC, Lobotesis K, White P, James MA, Bath P, Dineen RA, England TJ. Association between time to treatment and clinical outcomes in endovascular thrombectomy beyond 6 hours without advanced imaging selection. J Neurointerv Surg 2023; 15:336-342. [PMID: 35296526 DOI: 10.1136/neurintsurg-2021-018564] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/24/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The effectiveness and safety of endovascular thrombectomy (EVT) in the late window (6-24 hours) for acute ischemic stroke (AIS) patients selected without advanced imaging is undetermined. We aimed to assess clinical outcomes and the relationship with time-to-EVT treatment beyond 6 hours of stroke onset without advanced neuroimaging. METHODS Patients who underwent EVT selected with non-contrast CT/CT angiography (without CT perfusion or MR imaging), between October 2015 and March 2020, were included from a national stroke registry. Functional and safety outcomes were assessed in both early (<6 hours) and late windows with time analyzed as a continuous variable. RESULTS Among 3278 patients, 2610 (79.6%) and 668 (20.4%) patients were included in the early and late windows, respectively. In the late window, for every hour delay, there was no significant association with shift towards poorer functional outcome (modified Rankin Scale (mRS)) at discharge (adjusted common OR 0.98, 95% CI 0.94 to 1.01, p=0.27) or change in predicted functional independence (mRS ≤2) (24.5% to 23.3% from 6 to 24 hours; aOR 0.99, 95% CI0.94 to 1.04, p=0.85). In contrast, predicted functional independence was time sensitive in the early window: 5.2% reduction per-hour delay (49.4% to 23.5% from 1 to 6 hours, p=0.0001). There were similar rates of symptomatic intracranial hemorrhage (sICH) (3.4% vs 4.6%, p=0.54) and in-hospital mortality (12.9% vs 14.6%, p=0.33) in the early and late windows, respectively, without a significant association with time. CONCLUSION In this real-world study, there was minimal change in functional disability, sICH and in-hospital mortality within and across the late window. While confirmatory randomized trials are needed, these findings suggest that EVT remains feasible and safe when performed in AIS patients selected without advanced neuroimaging between 6-24 hours from stroke onset.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK .,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, The Royal London Hospital Barts Health NHS Trust, London, UK
| | | | - Oliver Spooner
- Stroke Medicine, The Royal London Hospital Barts Health NHS Trust, London, UK
| | - Kailash Krishnan
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alex Mortimer
- Interventional Neuroradiology, Southmead Hospital North Bristol NHS Trust, Bristol, Bristol, UK
| | - Thomas Calvert Booth
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, London, UK
| | - Philip White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Martin A James
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Philip Bath
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Robert A Dineen
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Mental Health and Clinical Neuroscience, School of Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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25
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Abdelrady M, Derraz I, Dargazanli C, Cheddad El Aouni M, Lefevre PH, Cagnazzo F, Riquelme C, Gascou G, Arquizan C, Mourand I, Ben Salem D, Costalat V, Gentric JC, Ognard J. Complete recanalization predicts favorable outcome in patients with distal M2-M3 middle cerebral artery occlusions following endovascular thrombectomy. J Neuroradiol 2023; 50:230-236. [PMID: 36436611 DOI: 10.1016/j.neurad.2022.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/18/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND - scanty articles illustrate the prognostic factors for favorable outcome after endovascular thrombectomy (EVT) in distal vessel occlusion (DMVO). Moreover, the current literature is diversified; conglomerating both primary, secondary, and anterior, posterior circulations embolic strokes in the same shell. PURPOSE to identify the association between complete reperfusion and favorable outcome following EVT for DMVO in the middle cerebral artery (MCA) territory. METHODS -we performed a retrospective analysis of prospectively maintained EVT registries at two comprehensive stroke centers between January 2015 and December 2019 for consecutive stroke patients with MCA-DMVO. DMVO was defined as an occlusion of distal M2 and M3 segments of the MCA. Only patients with primary isolated occlusions were included. A multivariate logistic regression was utilized to identify clinical and procedural-related factors associated with the 90-day favorable clinical outcome [defined as modified Rankin score (mRS) 0-2] after EVT. RESULTS -Out of 1823 within the registries; 66 patients (median age was 72 (60-78) and 59% were males) with primary isolated DMVO of the MCA were eligible for inclusion in the current study. Complete reperfusion was achieved in 56% (37/66) of the patients with no difference among the reperfusion strategies while the favorable outcome was observed in 68% (45/66). In the multivariate analysis, final complete reperfusion [modified Thrombolysis In Cerebral Infarction (mTICI) score 2c-3] was significantly associated with favorable outcome [aOR=7.69; (95% CI 1.73-34.17); p=.01], while higher baseline NIHSS score [aOR=0.82; (95% CI 0.69-0.98); p=.03] and increased imaging to puncture interval [aOR=0.99; (95% CI 0.98, 1.00); p=.01] decreased the probability of the favorable outcome. CONCLUSION according to our results, complete reperfusion was the most significant predictor of the favorable outcome, while higher baseline NIHSS and longer imaging to puncture interval decreased the probability of the favorable outcome.
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Affiliation(s)
- Mohamed Abdelrady
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France; Department of Neuroradiology, Hôpital Cavale Blanche, Brest University hospital, Brest, France; Department of Neuroradiology, El-Demerdash university hospital, Cairo, Egypt.
| | - Imad Derraz
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Mourad Cheddad El Aouni
- Department of Neuroradiology, Hôpital Cavale Blanche, Brest University hospital, Brest, France
| | - Pierre-Henri Lefevre
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Carlos Riquelme
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Isabelle Mourand
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Douraied Ben Salem
- Department of Neuroradiology, Hôpital Cavale Blanche, Brest University hospital, Brest, France
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University hospital, Montpellier, France
| | - Jean-Christophe Gentric
- Department of Neuroradiology, Hôpital Cavale Blanche, Brest University hospital, Brest, France
| | - Julien Ognard
- Department of Neuroradiology, Hôpital Cavale Blanche, Brest University hospital, Brest, France
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26
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Stösser S, Bode FJ, Meissner JN, Weller JM, Kindler C, Sauer M, Paech D, Riegler C, Nolte CH, Pourian A, Röther J, Selo N, Ernemann U, Poli S, Eckert RM, Bohner G, Scherling K, Dorn F, Petzold GC. Outcome of Stroke Patients with Unknown Onset and Unknown Time Last Known Well Undergoing Endovascular Therapy. Clin Neuroradiol 2023; 33:107-112. [PMID: 35796854 PMCID: PMC10014703 DOI: 10.1007/s00062-022-01188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Endovascular treatment (ET) in patients with large vessel occlusion stroke (LVOS) with unknown onset or an extended time window can be safe and effective if patients are selected by defined clinical and imaging criteria; however, it is unclear if these criteria should also be applied to patients with unknown onset and unknown time last known well. In this study, we aimed to assess whether absent information on the time patients were last known to be well impacts outcome in patients with unknown onset LVOS. METHODS We analyzed patients who were enrolled in the German Stroke Registry-Endovascular Treatment between 2015 and 2019. Patients with unknown onset and unknown time last known well (LKWu) were compared to patients with known onset (KO) and to patients with unknown onset but known time last known well (LKWk) regarding clinical and imaging baseline characteristics and outcome. RESULTS Out of 5909 patients, 561 presented with LKWu (9.5%), 1849 with LKWk (31.3%) and 3499 with KO (59.2%). At 90 days, functional independency was less frequent in LKWu (27.0%) compared to KO (42.6%) and LKWk patients (31.8%). These differences were not significant after adjusting for confounders. A main confounder was the initial Alberta stroke program early CT score. CONCLUSION The LKWu patients had a similar outcome after ET as KO and LKWk patients after adjusting for confounders. Thus, ET should not be withheld if the time last known well is unknown. Instead, LKWu patients may be selected for ET using the same criteria as in LKWk patients.
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Affiliation(s)
- Sebastian Stösser
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Julius N Meissner
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Johannes M Weller
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christine Kindler
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Malte Sauer
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Daniel Paech
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Amitis Pourian
- Department of Neurology, Asklepios Hospital Hamburg Altona, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Hospital Hamburg Altona, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Nadja Selo
- Department of Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Ulrike Ernemann
- Department of Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology, University Hospital Tübingen, Tübingen, Germany
| | - Rosa Marie Eckert
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Bohner
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Korbinian Scherling
- Department of Neuroradiology, Ludwig Maximilians University Munich, Campus Grosshadern, Munich, Germany
| | - Franziska Dorn
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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27
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Cancelliere NM, Hummel E, van Nijnatten F, van de Haar P, Withagen P, van Vlimmeren M, Hallacoglu B, Agid R, Nicholson P, Mendes Pereira V. The butterfly effect: improving brain cone-beam CT image artifacts for stroke assessment using a novel dual-axis trajectory. J Neurointerv Surg 2023; 15:283-287. [PMID: 35478176 PMCID: PMC9985729 DOI: 10.1136/neurintsurg-2021-018553] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/12/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cone-beam computed tomography (CBCT) imaging of the brain can be performed in the angiography suite to support various neurovascular procedures. Relying on CBCT brain imaging solely, however, still lacks full diagnostic confidence due to the inferior image quality compared with CT and various imaging artifacts that persist even with modern CBCT. OBJECTIVE To perform a detailed evaluation of image artifact improvement using a new CBCT protocol which implements a novel dual-axis 'butterfly' trajectory. METHODS Our study included 94 scans from 47 patients who received CBCT imaging for assessment of either ischemia or hemorrhage during a neurovascular procedure. Both a traditional uni-axis 'circular' and novel dual-axis 'butterfly' protocol were performed on each patient (same-patient control). Each brain scan was divided into six regions and scored out of 3 based on six artifacts originating from various physics-based and patient-based sources. RESULTS The dual-axis trajectory produces CBCT images with significantly fewer image artifacts than the traditional circular scan (whole brain average artifact score, AS: 0.20 vs 0.33), with the greatest improvement in bone beam hardening (AS: 0.13 vs 0.78) and cone-beam artifacts (AS: 0.04 vs 0.55). CONCLUSIONS Recent developments in CBCT imaging protocols have significantly improved image artifacts, which has improved diagnostic confidence for stroke and supports a direct-to-angiography suite transfer approach for patients with acute ischemic stroke.
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Affiliation(s)
- Nicole Mariantonia Cancelliere
- Departments of Neurosurgery and Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada .,Keenan Research Centre, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Eric Hummel
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | - Fred van Nijnatten
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | - Peter van de Haar
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | - Paul Withagen
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | | | - Bertan Hallacoglu
- Image Guided Therapy, Philips Healthcare, Best, Noord-Brabant, The Netherlands
| | - Ronit Agid
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Patrick Nicholson
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- Departments of Neurosurgery and Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
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28
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Dhillon PS, Butt W, Podlasek A, Barrett E, McConachie N, Lenthall R, Nair S, Malik L, James MA, Dineen RA, England TJ. Endovascular thrombectomy beyond 24 hours from ischemic stroke onset: a propensity score matched cohort study. J Neurointerv Surg 2023; 15:233-237. [PMID: 35169031 DOI: 10.1136/neurintsurg-2021-018591] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/30/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The safety and functional outcome of endovascular thrombectomy (EVT) in the very late (VL; >24 hours) time window from ischemic stroke onset remains undetermined. METHODS Using data from a national stroke registry, we used propensity score matched (PSM) individual level data of patients who underwent EVT, selected with CT perfusion or non-contrast CT/CT angiography, between October 2015 and March 2020. Functional and safety outcomes were assessed in both late (6-24 hours) and VL time windows. Subgroup analysis was performed of imaging selection modality in the VL time window. RESULTS We included 1150 patients (late window: 1046 (208 after PSM); VL window: 104 (104 after PSM)). Compared with EVT treatment initiation between 6 and 24 hours, patients treated in the VL window had similar modified Rankin Scale (mRS) scores at discharge (ordinal shift; common OR=1.08, 95% CI 0.69 to 1.47, p=0.70). No significant differences in achieving good functional outcome (mRS ≤2 at discharge; 28.8% (VL) vs 29.3% (late), OR=0.97, 95% CI 0.58 to 1.64, p=0.93), successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b-3) (p=0.77), or safety outcomes of symptomatic intracranial hemorrhage (p=0.43) and inhospital mortality (p=0.23) were demonstrated. In the VL window, there was no significant difference in functional outcome among patients selected with perfusion versus those selected without perfusion imaging (common OR=1.38, 95% CI 0.81 to 1.76, p=0.18). CONCLUSION In this real world study, EVT beyond 24 hours from stroke onset or last known well appeared to be feasible, with comparable safety and functional outcomes to EVT initiation between 6 and 24 hours. Randomized trials assessing the efficacy of EVT in the VL window are warranted, but may only be feasible with a large international collaborative approach.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK .,NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Emma Barrett
- Department of Research and Innovation (Medical Statistics), Manchester University NHS Foundation Trust, Manchester, UK.,Centre for Biostatistics, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin A James
- Exeter Medical School, University of Exeter, Exeter, UK.,Stroke, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Robert A Dineen
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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29
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Eriksson H, Nordanstig A, Rentzos A, Zelano J, Redfors P. Risk of poststroke epilepsy after reperfusion therapies: A national cohort study. Eur J Neurol 2023; 30:1303-1311. [PMID: 36692236 DOI: 10.1111/ene.15695] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE The risk of poststroke epilepsy (PSE) after endovascular treatment (EVT) is not well characterized. In this nationwide study, we assessed the risk of PSE after EVT and identified associated predictors. METHODS We included all individuals (n = 3319) treated with EVT (±intravenous thrombolysis [IVT]) between 2015 and 2019 in the Swedish National Quality Register for EVT. Two control groups were identified from the Swedish Stroke Register: the first treated with IVT alone (n = 3132) and the second with no treatment (n = 3184), both matched for age, sex, stroke severity, and time of stroke. RESULTS PSE developed in 7.9% (n = 410). The survival-adjusted 2-year risk was 6.5% (95% confidence interval [CI] = 5.28-7.70) after EVT, 10.0% (95% CI = 8.25-11.75) after IVT, and 12.3% after no revascularization (95% CI = 10.33-14.25). The hazard ratio (HR) of PSE after EVT was almost half compared to no treatment (HR = 0.51, 95% CI = 0.41-0.64). The risk of PSE after EVT was lower compared to no treatment in a multivariable Cox model that adjusted for age, sex, hemicraniectomy, and stroke severity (HR = 0.76, 95% CI = 0.60-0.96). Multivariable predictors of PSE after EVT were large infarction on computed tomography Day 1, high posttreatment National Institutes of Health Stroke Scale score, and need of assistance 3 months after stroke. IVT before EVT was associated with a lower risk of PSE (HR = 0.66, 95% CI = 0.46-0.94). CONCLUSIONS This nationwide study identified a reduced risk of PSE after EVT. Markers of severe infarction after EVT were associated with PSE, whereas IVT given before EVT was protective.
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Affiliation(s)
- Hanna Eriksson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alexandros Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Radiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Zelano
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
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30
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Jabal MS, Kallmes DF, Harston G, Campeau N, Schwartz K, Messina S, Carr C, Benson J, Little J, Nagelschneider A, Madhavan A, Nasr D, Braksick S, Klaas J, Scharf E, Bilgin C, Brinjikji W. Automated CT angiography collateral scoring in anterior large vessel occlusion stroke: A multireader study. Interv Neuroradiol 2023:15910199221150470. [PMID: 36650942 DOI: 10.1177/15910199221150470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Computed tomography (CT) angiography collateral score (CTA-CS) is an important clinical outcome predictor following mechanical thrombectomy for ischemic stroke with large vessel occlusion (LVO). The present multireader study aimed to evaluate the performance of e-CTA software for automated assistance in CTA-CS scoring. MATERIALS AND METHODS Brain CTA images of 56 patients with anterior LVO were retrospectively processed. Twelve readers of various clinical training, including junior neuroradiologists, senior neuroradiologists, and neurologists graded collateral flow using visual CTA-CS scale in two sessions separated by a washout period. Reference standard was the consensus of three expert readers. Duration of reading time, inter-rater reliability, and statistical comparison of readers' performance metrics were analyzed between the e-CTA assisted and unassisted sessions. RESULTS e-CTA assistance resulted in significant increase in mean accuracy (58.6% to 67.5%, p = 0.003), mean F1 score (0.574 to 0.676, p = 0.002), mean precision (58.8% to 68%, p = 0.007), and mean recall (58.7% to 69.9%, p = 0.002), especially with slight filling deficit (CTA-CS 2 and 3). Mean reading time was reduced across all readers (103.4 to 59.7 s, p = 0.001), and inter-rater agreement in CTA-CS assessment was increased (Krippendorff's alpha 0.366 to 0.676). Optimized occlusion laterality detection was also noted with mean accuracy (92.9% to 96.8%, p = 0.009). CONCLUSION Automated assistance for CTA-CS using e-CTA software provided helpful decision support for readers in terms of improving scoring accuracy and reading efficiency for physicians with a range of experience and training backgrounds and leading to significant improvements in inter-rater agreement.
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Affiliation(s)
| | - David F Kallmes
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - George Harston
- Brainomix Limited, Oxford, UK
- 6397Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Norbert Campeau
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Kara Schwartz
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Steven Messina
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Carrie Carr
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - John Benson
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Jason Little
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | | | - Ajay Madhavan
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Deena Nasr
- Department of Neurology, 6915Mayo Clinic, Rochester, MN, USA
| | - Sherry Braksick
- Department of Neurology, 6915Mayo Clinic, Rochester, MN, USA
| | - James Klaas
- Department of Neurology, 6915Mayo Clinic, Rochester, MN, USA
| | - Eugene Scharf
- Department of Neurology, 6915Mayo Clinic, Rochester, MN, USA
| | - Cem Bilgin
- Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
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31
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Levy EI, Monteiro A, Waqas M, Siddiqui AH. Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities. Neurosurgery 2023; 92:3-9. [PMID: 36519855 DOI: 10.1227/neu.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 12/23/2022] Open
Abstract
Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.
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Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
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32
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Bhurwani MMS, Boutelier T, Davis A, Gautier G, Swetz D, Rava RA, Raguenes D, Waqas M, Snyder KV, Siddiqui AH, Ionita CN. Identification of infarct core and ischemic penumbra using computed tomography perfusion and deep learning. J Med Imaging (Bellingham) 2023; 10:014001. [PMID: 36636489 PMCID: PMC9826796 DOI: 10.1117/1.jmi.10.1.014001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 12/20/2022] [Indexed: 01/10/2023] Open
Abstract
Purpose The size and location of infarct and penumbra are key to decision-making for acute ischemic stroke (AIS) management. CT perfusion (CTP) software estimate infarct and penumbra volume using contralateral hemisphere relative thresholding. This approach is not robust and widely contested by the scientific community. In this study, we investigate the use of deep learning-based algorithms to efficiently locate infarct and penumbra tissue on CTP hemodynamic maps. Approach CTP scans were retrospectively collected for 60 and 59 patients in the infarct only and infarct + penumbra substudies respectively. Commercial CTP software was used to generate cerebral blood flow, cerebral blood volume, mean transit time, time to peak, and delay time maps. U-Net-shaped architectures were trained to segment infarct or infarct + penumbra. Test-time-augmentation, ensembling, and watershed segmentation were used as postprocessing techniques. Segmentation performance was evaluated using Dice coefficients (DC) and mean absolute volume errors (MAVE). Results The algorithm segmented infarct tissue resulted in DC of 0.64 ± 0.03 (0.63, 0.65), and MAVE of 4.91 ± 0.94 (4.5, 5.32) mL. In comparison, the commercial software predicted infarct with a DC of 0.31 ± 0.17 (0.26, 0.36) and MAVE of 9.77 ± 8.35 (7.12, 12.42) mL. The algorithm was able to segment infarct + penumbra with a DC of 0.61 ± 0.04 (0.6, 0.63), and MAVE of 6.51 ± 1.37 (5.91, 7.11) mL. In comparison, the commercial software predicted infarct + penumbra with a DC of 0.3 ± 0.19 (0.25, 0.35) and MAVE of 9.18 ± 7.55 (7.25, 11.11) mL. Conclusions Use of deep learning algorithms to assess severity of AIS in terms of infarct and penumbra volume is precise and outperforms current relative thresholding methods. Such an algorithm would enhance the reliability of CTP in guiding treatment decisions.
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Affiliation(s)
- Mohammad Mahdi Shiraz Bhurwani
- University at Buffalo, Department of Biomedical Engineering, Buffalo, New York, United States
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States
| | | | | | | | - Dennis Swetz
- University at Buffalo, Department of Biomedical Engineering, Buffalo, New York, United States
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States
| | - Ryan A. Rava
- University at Buffalo, Department of Biomedical Engineering, Buffalo, New York, United States
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States
| | | | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States
- University at Buffalo, Department of Neurosurgery, Buffalo, New York, United States
| | - Kenneth V. Snyder
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States
- University at Buffalo, Department of Neurosurgery, Buffalo, New York, United States
| | - Adnan H. Siddiqui
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States
- University at Buffalo, Department of Neurosurgery, Buffalo, New York, United States
| | - Ciprian N. Ionita
- University at Buffalo, Department of Biomedical Engineering, Buffalo, New York, United States
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States
- University at Buffalo, Department of Neurosurgery, Buffalo, New York, United States
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Muacevic A, Adler JR, Nevin C, Ranasinghe T, Jacob S, Ferari C, Adcock A. Incidence of Atrial Fibrillation in Large Vessel Occlusion and Large Embolic Stroke of Undetermined Source. Cureus 2023; 15:e33700. [PMID: 36793841 PMCID: PMC9925036 DOI: 10.7759/cureus.33700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Large vessel occlusion (LVO) stroke is a common presentation of acute ischemic stroke and is often unknown or cryptogenic in etiology. There is a strong association between atrial fibrillation (AF) and cryptogenic LVO stroke, making it a unique stroke subgroup. Therefore, we propose that any LVO stroke meeting the criteria for an embolic stroke of an undetermined source (ESUS) be classified as large ESUS (LESUS). The purpose of this retrospective cohort study was to report the etiology of anterior LVO strokes that underwent endovascular thrombectomy. METHODS This was a single-center retrospective cohort study characterizing the etiology of acute anterior circulation LVO strokes that received emergent endovascular thrombectomy from 2011 to 2018. Patients with LESUS designation at hospital discharge were changed to cardioembolic etiology if AF was discovered during the two-year follow-up period. Results: Overall, 155 (45%) of 307 patients in the study were found to have AF. New onset AF was discovered in 12 (23%) of 53 LESUS patients after hospitalization. Furthermore, eight (35%) of 23 LESUS patients who received extended cardiac monitoring were found to have AF. CONCLUSION Nearly half the patients with LVO stroke who received endovascular thrombectomy were found to have AF. With the use of extended cardiac monitoring devices after hospitalization, AF is frequently discovered in patients with LESUS and may change the secondary stroke prevention strategy.
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Ma G, Yu Z, Jia B, Xian Y, Ren Z, Mo D, Ma N, Gao F, Tong X, Shi X, Li L, Pan Y, Miao Z. Time to Endovascular Reperfusion and Outcome in Acute Ischemic Stroke : A Nationwide Prospective Registry in China. Clin Neuroradiol 2022; 32:997-1009. [PMID: 35622100 DOI: 10.1007/s00062-022-01178-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/25/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The benefit of endovascular reperfusion therapy for acute ischemic stroke is highly time-dependent but the relation of delays in workflow with outcomes and the key determinants of delays remain uncertain. This study aimed to evaluate the association between faster endovascular therapy and outcomes in a Chinese population with acute ischemic stroke. METHODS Patients treated with endovascular therapy within 7 h due to anterior large vessel occlusion were enrolled in the ANGEL-ACT registry. Time intervals from hospital arrival to arterial puncture (door-to-puncture), hospital arrival to reperfusion (door-to-reperfusion) and puncture-to-reperfusion were recorded. The outcomes included modified Rankin Scale (mRS) scores 0-1, 0-2, mortality at 3 months, substantial reperfusion, and symptomatic intracranial hemorrhage (sICH). RESULTS Of 932 patients receiving endovascular therapy (mean age 65.1 years, 60.1% male), the median door-to-puncture, door-to-reperfusion, and puncture-to-perfusion times were 110min (interquartile range, IQR 72-155min), 200min (IQR, 149-260min), and 76min (IQR, 50-118min). Of the patients 87.4% achieved substantial reperfusion and 9.6% had sICH. The mRS 0-1, 0-2, and mortality at 3 months were 39.8%, 43.2%, and 16.4%. Faster door-to-reperfusion and puncture-to-reperfusion were associated with higher likelihood of mRS 0-1, mRS 0-2, and lower rate of sICH. There was a trend of improved mRS, lower mortality, and fewer ICH with shorter door-to-puncture time; however, most differences were not statistically significant. CONCLUSION Among patients with acute ischemic stroke in routine clinical practice, shorter time to reperfusion was associated with better outcome after endovascular therapy. Standardized workflows and training in endovascular treatment techniques should be promoted nationally to reduce in-hospital delays.
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Affiliation(s)
- Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Zequan Yu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Ying Xian
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Xiangqun Shi
- Department of Neurology, Shunde Hospital, Southern Medical University, Foshan, Guangdong, China
| | - Ling Li
- Department of Neurology, The Affiliated Hospital of Hebei University, Baoding, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China.
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China.
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Ueda T, Hasegawa Y, Takeuchi M, Morimoto M, Tsuboi Y, Yamamoto R, Kaku S, Ayabe J, Akiyama T, Ishima D, Mori K, Kagami H, Ito H, Onodera H, Doi H, Tsumoto T, Hataoka S, Noda M, Tomura N, Masuo O, Yoshida Y, Kaga Y, Tatsuno K, Yoshie T, Takaishi S, Yamano Y. Primary results of mechanical thrombectomy for acute ischemic stroke: The K-NET registry in the Japanese metropolitan area. Int J Stroke 2022; 18:607-614. [PMID: 36305084 DOI: 10.1177/17474930221138014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) for acute large vessel occlusion has proven to be effective in randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in a metropolitan area with a large number of comprehensive stroke centers and to compare it with the results of other registries and randomized controlled trials (RCTs). METHODS We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA). Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis. RESULTS The median age was 77 years, and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 min. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Overall mortality was 12.6%. Significant predictors for a good outcome were as follows: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization. CONCLUSION EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous studies, despite the high proportion of patients with older age, pretreatment mRS score of >2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.
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Affiliation(s)
- Toshihiro Ueda
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | | | | | | | | | | | - Shogo Kaku
- Neurosurgical East Yokohama Hospital, Yokohama, Japan
| | | | | | | | | | | | - Hidemichi Ito
- St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidetaka Onodera
- St. Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Hiroshi Doi
- Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | | | - Shunsuke Hataoka
- National Hospital Organization, Yokohama Medical Center, Yokohama, Japan
| | - Masayuki Noda
- Yokohama Shinmidori General Hospital, Yokohama, Japan
| | | | - Osamu Masuo
- Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | | | - Yasuyuki Kaga
- St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kentaro Tatsuno
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Tomohide Yoshie
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Satoshi Takaishi
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
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Dixon M, Appleton JP, Scutt P, Woodhouse LJ, Haywood LJ, Havard D, Williams J, Siriwardena AN, Bath PM. Time intervals and distances travelled for prehospital ambulance stroke care: data from the randomised-controlled ambulance-based Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2). BMJ Open 2022; 12:e060211. [PMID: 36410799 PMCID: PMC9680177 DOI: 10.1136/bmjopen-2021-060211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Ambulances offer the first opportunity to evaluate hyperacute stroke treatments. In this study, we investigated the conduct of a hyperacute stroke study in the ambulance-based setting with a particular focus on timings and logistics of trial delivery. DESIGN Multicentre prospective, single-blind, parallel group randomised controlled trial. SETTING Eight National Health Service ambulance services in England and Wales; 54 acute stroke centres. PARTICIPANTS Paramedics enrolled 1149 patients assessed as likely to have a stroke, with Face, Arm, Speech and Time score (2 or 3), within 4 hours of symptom onset and systolic blood pressure >120 mm Hg. INTERVENTIONS Paramedics administered randomly assigned active transdermal glyceryl trinitrate or sham. PRIMARY AND SECONDARY OUTCOMES Modified Rankin scale at day 90. This paper focuses on response time intervals, distances travelled and baseline characteristics of patients, compared between ambulance services. RESULTS Paramedics enrolled 1149 patients between September 2015 and May 2018. FINAL DIAGNOSIS intracerebral haemorrhage 13%, ischaemic stroke 52%, transient ischaemic attack 9% and mimic 26%. Timings (min) were (median (25-75 centile)): onset to emergency call 19 (5-64); onset to randomisation 71 (45-116); total time at scene 33 (26-46); depart scene to hospital 15 (10-23); randomisation to hospital 24 (16-34) and onset to hospital 97 (71-141). Ambulances travelled (km) 10 (4-19) from scene to hospital. Timings and distances differed between ambulance service, for example, onset to randomisation (fastest 53 min, slowest 77 min; p<0.001), distance from scene to hospital (least 4 km, most 20 km; p<0.001). CONCLUSION We completed a large prehospital stroke trial involving a simple-to-administer intervention across multiple ambulance services. The time from onset to randomisation and modest distances travelled support the applicability of future large-scale paramedic-delivered ambulance-based stroke trials in urban and rural locations. TRIAL REGISTRATION NUMBER ISRCTN26986053.
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Affiliation(s)
- Mark Dixon
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
- Leicester, Leicestershire & Rutland Division, East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Polly Scutt
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Lisa J Woodhouse
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Lee J Haywood
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Diane Havard
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Julia Williams
- Division of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | | | - Philip M Bath
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
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Li Z, Bi R, Sun S, Chen S, Chen J, Hu B, Jin H. The Role of Oxidative Stress in Acute Ischemic Stroke-Related Thrombosis. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:8418820. [PMID: 36439687 PMCID: PMC9683973 DOI: 10.1155/2022/8418820] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/13/2022] [Accepted: 11/02/2022] [Indexed: 09/22/2023]
Abstract
Acute ischemic stroke is a serious life-threatening disease that affects almost 600 million people each year throughout the world with a mortality of more than 10%, while two-thirds of survivors remain disabled. However, the available treatments for ischemic stroke are still limited to thrombolysis and/or mechanical thrombectomy, and there is an urgent need for developing new therapeutic target. Recently, intravascular oxidative stress, derived from endothelial cells, platelets, and leukocytes, has been found to be tightly associated with stroke-related thrombosis. It not only promotes primary thrombus formation by damaging endothelial cells and platelets but also affects thrombus maturation and stability by modifying fibrin components. Thus, oxidative stress is expected to be a novel target for the prevention and treatment of ischemic stroke. In this review, we first discuss the mechanisms by which oxidative stress promotes stroke-related thrombosis, then summarize the oxidative stress biomarkers of stroke-related thrombosis, and finally put forward an antithrombotic therapy targeting oxidative stress in ischemic stroke.
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Affiliation(s)
- Zhifang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shuai Sun
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shengcai Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jiefang Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Huijuan Jin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Gupta A, Garg PK, Khera PS, Panda S, Bohra GK, Yadav T, Garg MK, Tiwari S. Multiphase computed tomography angiography (mCTA) derived source images in acute ischemic stroke: Beyond collaterals. Can it obviate the need for computed tomography perfusion (CTP)? Clin Neurol Neurosurg 2022; 222:107421. [PMID: 36067545 DOI: 10.1016/j.clineuro.2022.107421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/16/2022] [Accepted: 08/20/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE To compare Multiphase CT Angiography derived source images (mCTA-SI) in acute ischemic stroke (AIS) with CT Perfusion (CTP) derived automated color maps of cerebral blood flow (CBF) and cerebral blood volume (CBV) and to assess the comparability of mCTA-SI with CTP in the prediction of final radiological and clinical outcome. METHODS This prospective single-centre observational study comprised of patients with AIS of the anterior circulation, presenting within 24 h and undergoing neuroimaging under stroke protocol with follow-up. Non-contrast computed tomography (NCCT), mCTA, and CTP were acquired with follow-up NCCT at 24 h and modified Rankin score (mRS) at 3 months. mCTA-SI and CTP color maps were scored by the ASPECTS (Alberta Stroke program early CT score) method and compared amongst each other and with the outcome. ROC (Receiver operating characteristic) curves were plotted considering mRS 0-2 and FIV≤ 28 ml as favourable clinical and radiological outcomes respectively. RESULTS The study included 55 patients. The 1st and 2nd phase of mCTA-SI correlated significantly with CBF maps (r = 0.845, p < 0.01, r = 0.842, p < 0.01 respectively). 3rd phase of mCTA-SI correlated significantly with CBV maps (r = 0.904, p < 0.01). A favourable functional and radiological outcome was best predicted by the 1st (AUC 0.8, 95%CI 0.671-0.896) and 2nd ( AUC 0.895, 95% CI 0.783-0.962) phase of mCTA-SI respectively. CONCLUSIONS The 1st and 2nd phases of mCTA-SI produces results congruent to CBF color maps and the 3rd phase of mCTA-SI simulate CBV color maps. In addition to predicting radiological and functional outcomes, mCTA can predict the salvageable and non-salvageable tissue in AIS and is non-inferior to CTP.
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Affiliation(s)
- Aanchal Gupta
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India.
| | - Pawan K Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India.
| | - Pushpinder S Khera
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India.
| | - Samhita Panda
- Department of Neurology, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India.
| | - Gopal K Bohra
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India.
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India.
| | - M K Garg
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India.
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India.
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Khazaal O, Cox M, Grodinsky E, Dawod J, Cristancho D, Atsina KB, Ji JY, Neuhaus-Booth E, Ramchand P, Pukenas BA, Kung D, Hurst R, Choudhri O, Burkhardt JK, Kasner SE, Favilla CG. Highly Visible Wall-Timer to Reduce Endovascular Treatment Time for Stroke. STROKE (HOBOKEN, N.J.) 2022; 2:e000300. [PMID: 37588009 PMCID: PMC10431196 DOI: 10.1161/svin.121.000300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/26/2022] [Indexed: 08/18/2023]
Abstract
BACKGROUND Endovascular therapy for acute ischemic stroke has revolutionized clinical care for patients with stroke and large vessel occlusion, but treatment remains time sensitive. At our stroke center, up to half of the door-to-groin time is accounted for after the patient arrives in the angio-suite. Here, we apply the concept of a highly visible timer in the angio-suite to quantify the impact on endovascular treatment time. METHODS This was a single-center prospective pseudorandomized study conducted over a 32-week period. Pseudorandomization was achieved by turning the timer on and off in 2-week intervals. The primary outcome was angio-suite-to-groin time, and secondary outcomes were angio-suite-to-intubation time, groin-to-recanalization time, and 90-day modified Rankin scale. A stratified analysis was performed based on type of anesthesia (ie, endotracheal intubation versus not). RESULTS During the 32-week study period, 97 mechanical thrombectomies were performed. The timer was on and off for 38 and 59 cases, respectively. The timer resulted in faster angio-suite-to-groin time (28 versus 33 minutes; P=0.02). The 5-minute reduction in angio-suite-to-groin was maintained after adjusting for intubation status in a multivariate regression (P=0.02). There was no difference in the 90-day modified Rankin scale between groups. The timer impact was consistent across the 32-week study period. CONCLUSIONS A highly visible timer in the angio-suite achieved a meaningful, albeit modest, reduction in endovascular treatment time for patients with stroke. Given the lack of risk and low cost, it is reasonable for stroke centers to consider a highly visible timer in the angio-suite to improve treatment times.
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Affiliation(s)
- Ossama Khazaal
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Mougnyan Cox
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Emily Grodinsky
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Judy Dawod
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Daniel Cristancho
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Kofi-Buaku Atsina
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Jonathan Y Ji
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Elizabeth Neuhaus-Booth
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Preethi Ramchand
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Bryan A Pukenas
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - David Kung
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Robert Hurst
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Omar Choudhri
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Jan-Karl Burkhardt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
| | - Christopher G Favilla
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (O.K., E.G., J.D., D.C., E.N.-B., P.R., S.E.K., C.G.F.); Department of Radiology, University of Pennsylvania, Philadelphia, PA (M.C., K.-B.A., J.Y.J., B.A.P., R.H.); Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA (D.K., O.C., J.-K.B.)
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Yang X, Yang J, Sun D, Wang A, Tong X, Jia B, Miao Z. Comparison of predictors of failure of early neurological improvement after successful endovascular treatment for posterior and anterior circulation large vessel occlusion: Data from ANGEL-ACT registry. Interv Neuroradiol 2022:15910199221133164. [PMID: 36266940 DOI: 10.1177/15910199221133164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To identify and compare the predictors of failure of early neurological improvement (fENI)after successful EVT for anterior circulation large vessel occlusion (ACLVO) and posterior circulation LVO (PCLVO). METHODS Subjects were selected from the ANGEL-ACT registry. fENI was defined as unchanged or worsened in National Institutes of Health Stroke Scale score (NIHSS) between admission and 24 h after EVT. Predictors of fENI after successful EVT (mTICI 2b-3) were determined via center-adjusted analyses. Univariable and multivariable comparisons between ACLVO and PCLVO were performed. RESULTS A total of 1447 patients, 1128 were with ACLVO, and 319 were with PCLVO. Among the patients with ACLVO, there were 409 patients (36.3%) with fENI and 719 patients (63.7%) with ENI. We observed that pre-stroke mRS scale score of 2 (odd ratio[OR] 95% confidence interval[CI], 6.93[1.99-24.10], P = 0.002), initial NIHSS score (OR per point[95%CI], 0.97[0.95-0.99], P = 0.012), diabetes (OR[95%CI], 1.56[1.08-2.25], P = 0.017), previous ICH (OR[95%CI] 9.21[1.76-48.15], P = 0.008), local anesthesia (OR[95%CI] 1.63[1.10-2.42], P = 0.014), onset-to-puncture time (OR[95%CI], 1.001[1.000-1.001], P = 0.009), symptomatic ICH (OR[95%CI] 3.90[2.27-6.69], P < 0.001), and continued use of tirofiban within 2 h after EVT (OR[95%CI], 0.69[0.51-0.93], P = 0.014) were independent predictors of fENI of ACLVO after EVT. Among the patients with PCLVO, there were 112 patients (35.1%) with fENI and 207 patients (64.9%) with ENI. In contrast, admission SBP (OR[95%CI], 0.98[0.97-0.99], P = 0.012), and vascular dissection within 2 h after EVT (OR[95%CI], 7.23[1.33-39.13], P = 0.022) were independent predictors of fENI of PCLVO after EVT. CONCLUSION In selected patients, successful EVT can lead to similar outcomes in PCLVO and ACLVO. Some predictors of fENI in both anterior circulation and posterior circulation were identified in our study, which should be highly considered in the clinical practice in LVO patients undergoing EVT.
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Affiliation(s)
- Xinguang Yang
- Department of Neurology, 56713Sun Yat-sen Memorial Hospital, 56713Sun Yat-sen University, Guangzhou, China
| | - Jie Yang
- Department of Neurology, 220741the Second Affiliated Hospital of GuangZhou Medical University, Guangzhou, China
| | - Dapeng Sun
- 571014Department of Interventional Neuroradiology, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- 571014Department of Interventional Neuroradiology, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- 571014Department of Interventional Neuroradiology, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- 571014Department of Interventional Neuroradiology, 105738Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Miyamoto S, Kato N, Yamazaki T, Yamano A, Akutsu Y, Yasuda S, Matsumaru Y, Ishikawa E. Direct Carotid-Cavernous Fistula Caused by Internal Carotid Artery Perforation by a Microcatheter Body during Mechanical Thrombectomy. Asian J Neurosurg 2022; 17:638-641. [PMID: 36570747 PMCID: PMC9771614 DOI: 10.1055/s-0042-1757629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rapid advances in emergent mechanical thrombectomy have resulted in a higher occurrence of arterial perforations during neurointerventions. Here, we report a case of internal carotid artery (ICA) perforation during mechanical thrombectomy in a 78-year-old man with a left middle cerebral artery occlusion. The ICA was perforated by a microcatheter during thrombectomy, forming a direct carotid-cavernous fistula. A two-stage drainer occlusion was conducted because of cortical venous reflex aggravation and ocular symptoms. Here, we report the perforation details and treatment, adding to evidence that ICA perforation with the microcatheter body is a concern during mechanical thrombectomy.
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Affiliation(s)
- Satoshi Miyamoto
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan,Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Tomosato Yamazaki
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Akinari Yamano
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Yoshimitsu Akutsu
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Susumu Yasuda
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan,Address for correspondence Eiichi Ishikawa, MD, PhD Department of Neurosurgery, Faculty of Medicine, University of TsukubaTsukuba, Ibaraki, 305-8575Japan
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Docosahexaenoic Acid Alleviates Brain Damage by Promoting Mitophagy in Mice with Ischaemic Stroke. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3119649. [PMID: 36254232 PMCID: PMC9569200 DOI: 10.1155/2022/3119649] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/04/2022] [Accepted: 09/15/2022] [Indexed: 12/06/2022]
Abstract
Mitophagy, the selective removal of damaged mitochondria through autophagy, is crucial for mitochondrial turnover and quality control. Docosahexaenoic acid (DHA), an essential omega-3 fatty acid, protects mitochondria in various diseases. This study aimed to investigate the neuroprotective role of DHA in ischaemic stroke models in vitro and in vivo and its involvement in mitophagy and mitochondrial dysfunction. A mouse model of ischaemic stroke was established through middle cerebral artery occlusion (MCAO). To simulate ischaemic stroke in vitro, PC12 cells were subjected to oxygen–glucose deprivation (OGD). Immunofluorescence analysis, western blotting (WB), electron microscopy (EM), functional behavioural tests, and Seahorse assay were used for analysis. DHA treatment significantly alleviated the brain infarction volume, neuronal apoptosis, and behavioural dysfunction in mice with ischaemic stroke. In addition, DHA enhanced mitophagy by significantly increasing the number of autophagosomes and LC3-positive mitochondria in neurons. The Seahorse assay revealed that DHA increased glutamate and succinate metabolism in neurons after ischaemic stroke. JC-1 and MitoSox staining, and evaluation of ATP levels indicated that DHA-induced mitophagy alleviated reactive oxygen species (ROS) accumulation and mitochondrial injury. Mechanistically, DHA improved mitochondrial dynamics by increasing the expression of dynamin-related protein 1 (Drp1), LC3, and the mitophagy clearance protein Pink1/Parkin. Mdivi-1, a specific mitophagy inhibitor, abrogated the neuroprotective effects of DHA, indicating that DHA protected neurons by enhancing mitophagy. Therefore, DHA can protect against neuronal apoptosis after stroke by clearing the damaged mitochondria through Pink1/Parkin-mediated mitophagy and by alleviating mitochondrial dysfunction.
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Lu VM, Luther EM, Silva MA, Elarjani T, Abdelsalam A, Maier I, Al Kasab S, Jabbour PM, Kim JT, Wolfe SQ, Rai AT, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Polifka A, Mascitelli J, Osbun J, Park MS, Levitt MR, Dumont T, Cuellar H, Williamson RW, Romano DG, Crosa R, Gory B, Mokin M, Moss M, Limaye K, Kan P, Yavagal DR, Spiotta AM, Starke RM. Prognostic significance of age within the adolescent and young adult acute ischemic stroke population after mechanical thrombectomy: insights from STAR. J Neurosurg Pediatr 2022; 30:448-454. [PMID: 35986724 DOI: 10.3171/2022.7.peds22250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. METHODS A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12-18 (adolescent) and 19-25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. RESULTS Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0-2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to-groin puncture and groin puncture-to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0-6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01). CONCLUSIONS Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.
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Affiliation(s)
- Victor M Lu
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Evan M Luther
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Michael A Silva
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Turki Elarjani
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Ahmed Abdelsalam
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Ilko Maier
- 2Department of Neurology, University Medical Center Gottingen, Gottingen, Germany
| | - Sami Al Kasab
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Pascal M Jabbour
- 4Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joon-Tae Kim
- 5Department of Neurosurgery, Chonnam National University Hospital, Gwangju, South Korea
| | - Stacey Q Wolfe
- 6Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ansaar T Rai
- 7Department of Neuroradiology, University of West Virginia, Morgantown, West Virginia
| | | | | | - Adam S Arthur
- 10Department of Neurosurgery, Semmes Murphey Neurologic and Spine Clinic, Memphis, Tennessee
| | - Shinichi Yoshimura
- 11Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | - Ali Alawieh
- 12Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Isabel Fragata
- 13Department of Neuroradiology, Hospital Sao Jose Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Adam Polifka
- 14Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Justin Mascitelli
- 15Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Joshua Osbun
- 16Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri
| | - Min S Park
- 17Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael R Levitt
- 18Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Travis Dumont
- 19Department of Neurosurgery, University of Arizona, Tucson, Arizona
| | - Hugo Cuellar
- 20Department of Radiology, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Richard W Williamson
- 21Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Daniele G Romano
- 22Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Salerna, Italy
| | - Roberto Crosa
- 23Department of Neurosurgery, Neurological Endovascular Center, Medica Uruguaya, Montevideo, Uruguay
| | - Benjamin Gory
- 24Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- 25Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Mark Moss
- 26Department of Interventional Neuroradiology, Washington Regional Medical, Fayetteville, Arkansas
| | - Kaustubh Limaye
- 27Department of Interventional Neuroradiology, Indiana University, Indianapolis, Indiana; and
| | - Peter Kan
- 28Department of Neurosurgery, University of Texas Medical Branch-Galveston, Galveston, Texas
| | - Dileep R Yavagal
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Alejandro M Spiotta
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Robert M Starke
- 1Department of Neurosurgery, University of Miami, Miami, Florida
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McHugh DC, George BP, Bender MT, Horowitz RK, Kaufman DC, Holloway RG, Roberts DE. Reversal of Advanced Directives in Neurologic Emergencies. Neurohospitalist 2022; 12:651-658. [PMID: 36147771 PMCID: PMC9485691 DOI: 10.1177/19418744221097348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Objective Patients with advanced directives or Medical Orders for Life-Sustaining Treatment (MOLST), including "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI), may be candidates for procedural interventions when presenting with acute neurologic emergencies. Such interventions may limit morbidity and mortality, but typically they require MOLST reversal. We investigated outcomes of patients with MOLST reversal for treatment of neurologic emergencies. Methods We conducted a retrospective chart review from July 1, 2019 to April 30, 2021 of patients with MOLST reversal treated in our NeuroMedicine Intensive Care Unit. Variables collected include neurologic disease, MOLST reversal decision maker, procedural interventions, and outcomes. Results Twenty-seven patients (18 female, median age 78 years (IQR 73-85 years), median baseline modified Rankin score 1 [IQR 0-2.5] were identified with MOLST reversal. The most common pre-procedural MOLST was DNR/DNI (n=22, 81%), and 93% (n=25) pre-procedural MOLSTs were completed by the patient. MOLSTs were reversed by surrogates in n=23 cases (85%). The median time from MOLST completion to MOLST reversal was 603 days (IQR 45 days to 4 years). The most common neurologic emergency was ischemic stroke (n=14, 52%). Most patients died (n=14, 52%), 26% (n=7) were discharged to skilled nursing, and 22% (n=6) returned to home or assisted living. Conclusions In neurologic emergencies, urgent shared decision making is needed to ensure goal-concordant care, which may result in reversal of existing advanced directives. Outcomes of patients with MOLST reversal were heterogeneous, emphasizing the importance of deliberate patient-centered care weighing the risks and benefits of each intervention.
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Affiliation(s)
- Daryl C. McHugh
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin P. George
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert K. Horowitz
- Department of Medicine, Division of Palliative Care, University of Rochester Medical Center, Rochester, NY, USA
| | - David C. Kaufman
- Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert G. Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Debra E. Roberts
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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Bakke I, Lund CG, Carlsson M, Salvesen R, Normann B. Barriers to and facilitators for making emergency calls - a qualitative interview study of stroke patients and witnesses. J Stroke Cerebrovasc Dis 2022; 31:106734. [PMID: 36037678 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/14/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early access to hospital for diagnosis and treatment is strongly recommended for patients with acute stroke. Unfortunately, prehospital delay frequently occurs. The aim of the current study was to gain in-depth insight into patient experience and behavior in the prehospital phase of a stroke. METHODS We conducted qualitative interviews with a purposive sample of 11 patients and six witnesses within four weeks post stroke. The interviews were audio recorded, transcribed, and analyzed utilizing Systematic Text Condensation. RESULTS The material was classified according to two main categories each containing three subgroups. The first category contained the diversity of sudden changes that all participants noticed. The subgroups were confusing functional changes, distinct bodily changes and witnesses' observations of abnormal behavior or signs. The second category was delaying and facilitating factors. To trivialize or deny stroke symptoms, or having a high threshold for contacting emergency services, led to time delay. Factors facilitating early contact were severe stroke symptoms, awareness of the consequences of stroke or a witness standing by when the stroke occurred. CONCLUSIONS Prehospital delays involved interrelated elements: (1) Difficulties in recognition of a stroke when symptoms were mild, odd and/or puzzling; (2) Recognition of a stroke or need for medical assistance were facilitated by interaction/communication; (3) High threshold for calling emergency medical services, except when symptoms were severe. The findings may be helpful in planning future public stroke campaigns and in education and training programs for health personnel.
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Affiliation(s)
- Ida Bakke
- Patient Safety Unit, Nordland Hospital Trust, Bodø, Norway; Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.
| | | | - Maria Carlsson
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway; Department of Neurology, Nordland Hospital Trust, Bodø, Norway
| | - Rolf Salvesen
- Department of Neurology, Nordland Hospital Trust, Bodø, Norway
| | - Britt Normann
- Faculty of Nursing and Health Science, Nord University, Bodø, Norway; Department of Physiotherapy, Nordland Hospital Trust, Bodø, Norway
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Yan Chan JC, Edward Chu YL, Wei Cheung IH, On Tsang AC, Lau KK, Lee R. Direct Carotid Puncture for Mechanical Thrombectomy in Acute Ischemic Stroke: Literature Review and a Single-Center Experience. World Neurosurg 2022; 163:e301-e309. [PMID: 35367393 DOI: 10.1016/j.wneu.2022.03.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) for acute ischemic stroke via direct carotid puncture (DCP) has been commonly reported as case reports and series in the literature. However, the reported procedural risk and therapeutic outcome associated with this approach were variable. In this study, we aim to establish the role and safety profile of this alternative access technique by describing our single-center experience and conducting a comprehensive review of the literature. METHODS We conducted a retrospective review of consecutive patients at our center with large vessel occlusion (LVO) treated between 2018 and 2020 with DCP access. In addition, a literature review of studies published from 2012-2021 following PRISMA guidelines was conducted. RESULTS During the 3-year period, 11 patients with LVO were treated with EVT using DCP technique in our local cohort. A total of 216 cases were found in the literature search. A combined total of 227 cases were reviewed separately and collectively. Combining the data, DCP access was successfully achieved in 93.3% of the cases; 76.6% achieved satisfactory recanalization (mTICI ≥2b). DCP-related complications were seen in 20.3% of cases. A total of 32.4% patients were functionally independent (mRS ≤2) upon follow-up. CONCLUSIONS Results from the literature review and our experience illustrate DCP as a feasible approach for EVT. The role of DCP as a bailout is iterated despite a higher complication risk, which may be imperative in low-volume stroke centers. Further studies to evaluate the role of DCP as a primary vascular access technique for EVT in selected cases could be explored.
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Affiliation(s)
| | | | | | | | - Kui Kai Lau
- The State Key Laboratory of Brain and Cognitive Science, The University of Hong Kong, Hong Kong
| | - Raymand Lee
- Department of Radiology, Queen Mary Hospital, Hong Kong
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Li J, Zhu W, Zhou J, Yun W, Li X, Guan Q, Lv W, Cheng Y, Ni H, Xie Z, Li M, Zhang L, Xu Y, Zhang Q. A Presurgical Unfavorable Prediction Scale of Endovascular Treatment for Acute Ischemic Stroke. Front Aging Neurosci 2022; 14:942285. [PMID: 35847671 PMCID: PMC9284674 DOI: 10.3389/fnagi.2022.942285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo develop a prognostic prediction model of endovascular treatment (EVT) for acute ischemic stroke (AIS) induced by large-vessel occlusion (LVO), this study applied machine learning classification model light gradient boosting machine (LightGBM) to construct a unique prediction model.MethodsA total of 973 patients were enrolled, primary outcome was assessed with modified Rankin scale (mRS) at 90 days, and favorable outcome was defined using mRS 0–2 scores. Besides, LightGBM algorithm and logistic regression (LR) were used to construct a prediction model. Then, a prediction scale was further established and verified by both internal data and other external data.ResultsA total of 20 presurgical variables were analyzed using LR and LightGBM. The results of LightGBM algorithm indicated that the accuracy and precision of the prediction model were 73.77 and 73.16%, respectively. The area under the curve (AUC) was 0.824. Furthermore, the top 5 variables suggesting unfavorable outcomes were namely admitting blood glucose levels, age, onset to EVT time, onset to hospital time, and National Institutes of Health Stroke Scale (NIHSS) scores (importance = 130.9, 102.6, 96.5, 89.5 and 84.4, respectively). According to AUC, we established the key cutoff points and constructed prediction scale based on their respective weightings. Then, the established prediction scale was verified in raw and external data and the sensitivity was 80.4 and 83.5%, respectively. Finally, scores >3 demonstrated better accuracy in predicting unfavorable outcomes.ConclusionPresurgical prediction scale is feasible and accurate in identifying unfavorable outcomes of AIS after EVT.
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Affiliation(s)
- Jingwei Li
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
- Institute of Brain Sciences, Nanjing University, Nanjing, China
- Jiangsu Key Laboratory for Molecular Medicine, Medical School of Nanjing University, Nanjing, China
- Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing, China
- Nanjing Neurology Clinic Medical Center, Nanjing, China
| | - Wencheng Zhu
- The Institute of Software, Chinese Academy of Sciences, Beijing, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wenwei Yun
- Department of Neurology, Changzhou No.2 People's Hospital Affiliated to Nanjing Medical University, Changzhou, China
| | - Xiaobo Li
- Department of Neurology, Northern Jiangsu People's Hospital, Clinical Medical School of Yangzhou University, Yangzhou, China
| | - Qiaochu Guan
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
| | - Weiping Lv
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
| | - Yue Cheng
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
| | - Huanyu Ni
- Department of Pharmacy of Drum Tower Hospital, Medical School, Nanjing University, Nanjing, China
| | - Ziyi Xie
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
| | - Mengyun Li
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
| | - Lu Zhang
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
| | - Yun Xu
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
- Institute of Brain Sciences, Nanjing University, Nanjing, China
- Jiangsu Key Laboratory for Molecular Medicine, Medical School of Nanjing University, Nanjing, China
- Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing, China
- Nanjing Neurology Clinic Medical Center, Nanjing, China
| | - Qingxiu Zhang
- Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, China
- Institute of Brain Sciences, Nanjing University, Nanjing, China
- Jiangsu Key Laboratory for Molecular Medicine, Medical School of Nanjing University, Nanjing, China
- Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing, China
- Nanjing Neurology Clinic Medical Center, Nanjing, China
- *Correspondence: Qingxiu Zhang
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48
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Bertog SC, Sievert K, Grunwald IQ, Sharma A, Hornung M, Kühn AL, Vaskelyte L, Hofmann I, Gafoor S, Reinartz M, Matic P, Sievert H. Acute Stroke Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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49
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Derraz I. The End of Tissue-Type Plasminogen Activator's Reign? Stroke 2022; 53:2683-2694. [PMID: 35506385 DOI: 10.1161/strokeaha.122.039287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mechanical thrombectomy is a highly effective treatment for acute ischemic stroke caused by large-vessel occlusion in the anterior cerebral circulation, significantly increasing the likelihood of recovery to functional independence. Until recently, whether intravenous thrombolysis before mechanical thrombectomy provided additional benefits to patients with acute ischemic stroke-large-vessel occlusion remained unclear. Given that reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke-large-vessel occlusion and the efficacy of both intravenous thrombolysis and mechanical thrombectomy is time-dependent, achieving complete reperfusion with a single pass should be the primary angiographic goal. However, it remains undetermined whether extending the procedure with additional endovascular attempts or local lytics administration safely leads to higher reperfusion grades and whether there are significant public health and cost implications. Here, we outline the current state of knowledge and research avenues that remain to be explored regarding the consistent therapeutic benefit of intravenous thrombolysis in anterior circulation strokes and the potential place of adjunctive intra-arterial lytics administration, including alternative thrombolytic agent place.
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Affiliation(s)
- Imad Derraz
- Department of Neuroradiology, Hôpital Guide Chauliac, Montpellier University Medical Center, France
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50
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Pressman E, Sommer KN, Waqas M, Siddiqui AH, Ionita CN, Mokin M. Comparison of stent retriever thrombectomy using 3-dimensional patient-specific models of intracranial circulation with actual middle cerebral artery occlusion thrombectomy cases. J Neuroimaging 2022; 32:436-441. [PMID: 34958701 PMCID: PMC9899120 DOI: 10.1111/jon.12961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Stent retriever (SR) thrombectomy is commonly used for the treatment of emergent large vessel occlusion (ELVO) in acute ischemic stroke. Clot imaging parameters such as clot length, diameter, distance to the internal carotid artery terminus, and vessel angle where the SR is deployed may predict the likelihood of achieving first pass effect (FPE). Most of the proposed factors that seem to affect recanalization success have been studied individually, and conflicting data derived from clinical versus in vitro studies using 3-dimensional printed models of intracranial circulation currently exist. METHODS Using patient-specific 3-dimensional phantoms of the cervical and intracranial circulation, we simulated middle cerebral arteries (MCA) M1 and M2 occlusions treated with SR thrombectomy using Solitaire (Medtronic) or Trevo (Styker). Our primary outcome was FPE, defined as Thrombolysis in Cerebral Infarction score of 2c-3 achieved after a single thrombectomy attempt. We also performed retrospective analysis of same clot imaging characteristics of consecutive cases of MCA occlusion and its association with FPE matching the 3-dimensional in vitro experiments. Analysis was conducted using IBM SPSS Statistics Version 25 (IBM Corp., Armonk, NY). Chi-square tests and bivariate logistic regressions were the main statistical tests used in analysis. A p-value of less than .05 was considered to indicate statistical significance. Ninety-five confidence intervals (95% CI) were generated. RESULTS We compared 41 thrombectomy experiments performed using patient-specific 3-dimensional in vitro models with a retrospective cohort of 41 patients treated with SR thrombectomy. We found that in the in vitro cohort, higher MCA angulation was associated with a lower likelihood of FPE (odds ratio [OR] = 0.967, 95% CI = 0.944-0.991, p = .008). Meanwhile in the in vivo cohort, higher MCA angulation was associated with a higher likelihood of FPE (OR = 1.039, 95% CI = 1.003-1.077, p = .033). Neither clot length nor location of clot (M1 vs. M2) was associated with a difference in FPE rates in either cohort. DISCUSSION Comparison of SR thrombectomy performed during actual MCA occlusion cases versus patient-specific 3-dimensional replicas revealed MCA angulation as an independent predictor of procedure success or failure. However, the opposite direction of effect was observed between the two studied environments, indicating potential limitations of studying SR thrombectomy using 3-dimensional models of LVO.
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Affiliation(s)
- Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida 33620
| | - Kelsey N Sommer
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Mohammad Waqas
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208
| | - Adnan H Siddiqui
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208,Department of Neurosurgery, University at Buffalo, Buffalo, NY 14208
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo NY 14228,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY 14208
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida 33620
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