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Sarraj A, Pujara DK, Campbell BC. Current State of Evidence for Neuroimaging Paradigms in Management of Acute Ischemic Stroke. Ann Neurol 2024; 95:1017-1034. [PMID: 38606939 DOI: 10.1002/ana.26925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 04/13/2024]
Abstract
Stroke is the chief differential diagnosis in patient presenting to the emergency room with abrupt onset focal neurological deficits. Neuroimaging, including non-contrast computed tomography (CT), magnetic resonance imaging (MRI), vascular and perfusion imaging, is a cornerstone in the diagnosis and treatment decision-making. This review examines the current state of evidence behind the different imaging paradigms for acute ischemic stroke diagnosis and treatment, including current recommendations from the guidelines. Non-contrast CT brain, or in some centers MRI, can help differentiate ischemic stroke and intracerebral hemorrhage (ICH), a pivotal juncture in stroke diagnosis and treatment algorithm, especially for early window thrombolytics. Advanced imaging such as MRI or perfusion imaging can also assist making a diagnosis of ischemic stroke versus mimics such as migraine, Todd's paresis, or functional disorders. Identification of medium-large vessel occlusions with CT or MR angiography triggers consideration of endovascular thrombectomy (EVT), with additional perfusion imaging help identify salvageable brain tissue in patients who are likely to benefit from reperfusion therapies, particularly in the ≥6 h window. We also review recent advances in neuroimaging and ongoing trials in key therapeutic areas and their imaging selection criteria to inform the readers on potential future transitions into use of neuroimaging for stroke diagnosis and treatment decision making. ANN NEUROL 2024;95:1017-1034.
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Affiliation(s)
- Amrou Sarraj
- University Hospital Cleveland Medical Center-Case Western Reserve University, Neurology, Cleveland, Ohio, USA
| | - Deep K Pujara
- University Hospital Cleveland Medical Center-Case Western Reserve University, Neurology, Cleveland, Ohio, USA
| | - Bruce Cv Campbell
- The Royal Melbourne Hospital-The Florey Institute for Neuroscience and Mental Health, Medicine and Neurology, Parkville, Australia
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Scutelnic A, van de Munckhof A, Miraclin AT, Aaron S, Hameed S, Wasay M, Grosu O, Krzywicka K, Sánchez van Kammen M, Lindgren E, Moreira T, Acampora R, Negro A, Karapanayiotides T, Yaghi S, Revert A, Cuadrado Godia E, Garcia-Madrona S, La Spina P, Grillo F, Giammello F, Nguyen TN, Abdalkader M, Buture A, Sofia Cotelli M, Raposo N, Tsivgoulis G, Candelaresi P, Ciacciarelli A, Mbroh J, Batenkova T, Scoppettuolo P, Zedde M, Pascarella R, Antonenko K, Kristoffersen ES, Kremer Hovinga JA, Jood K, Aguiar de Sousa D, Poli S, Tatlisumak T, Putaala J, Coutinho JM, Ferro JM, Arnold M, Heldner MR. Characteristics and outcomes of cerebral venous thrombosis associated with COVID-19. Eur Stroke J 2024:23969873241241885. [PMID: 38572798 DOI: 10.1177/23969873241241885] [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: 04/05/2024] Open
Abstract
INTRODUCTION Previous reports and meta-analyses derived from small case series reported a mortality rate of up to 40% in patients with coronavirus disease 2019 associated cerebral venous thrombosis (COVID-CVT). We assessed the clinical characteristics and outcomes in an international cohort of patients with COVID-CVT. PATIENTS AND METHODS This was a registry study of consecutive COVID-CVT patients diagnosed between March 2020 and March 2023. Data collected by the International Cerebral Venous Thrombosis Consortium from patients with CVT diagnosed between 2017 and 2018 served as a comparison. Outcome analyses were adjusted for age and sex. RESULTS We included 70 patients with COVID-CVT from 23 hospitals in 15 countries and 206 controls from 14 hospitals in 13 countries. The proportion of women was smaller in the COVID-CVT group (50% vs 68%, p < 0.01). A higher proportion of COVID-CVT patients presented with altered mental state (44% vs 25%, p < 0.01), the median thrombus load was higher in COVID-CVT patients (3 [IQR 2-4] vs 2 [1-3], p < 0.01) and the length of hospital stay was longer compared to controls (11 days [IQR 7-20] vs 8 [4-15], p = 0.02). In-hospital mortality did not differ (5/67 [7%, 95% CI 3-16] vs 7/206 [3%, 2-7], aOR 2.6 [95% CI 0.7-9]), nor did the frequency of functional independence after 6 months (modified Rankin Scale 0-2; 45/58 [78%, 95% CI 65-86] vs 161/185 [87%, 81-91], aOR 0.5 [95% CI 0.2-1.02]). CONCLUSION In contrast to previous studies, the in-hospital mortality rate and functional outcomes during follow-up did not differ between COVID-CVT patients and the pre-COVID-19 controls.
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Affiliation(s)
- Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Angel T Miraclin
- Department of Neurosciences, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurosciences, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | | | | - Oxana Grosu
- Institute of Neurology and Neurosurgery "Diomid Gherman," Chisinau, Republic of Moldova
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Tiago Moreira
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Roberto Acampora
- Department of Neurology and Stroke Unit, Ospedale del Mare Hospital, Naples, Italy
| | - Alberto Negro
- Department of Neurology and Stroke Unit, Ospedale del Mare Hospital, Naples, Italy
| | - Theodoros Karapanayiotides
- 2nd Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Greece
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| | - Anna Revert
- Hospital del Mar, Faculty of Medicine and Life Sciences, Pompeu Fabra University Barcelona, Spain
| | - Elisa Cuadrado Godia
- Hospital del Mar, Faculty of Medicine and Life Sciences, Pompeu Fabra University Barcelona, Spain
| | | | - Paolino La Spina
- Translational Molecular Medicine and Surgery 36th Cycle, Department of BIOMORF, Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Francesco Grillo
- Translational Molecular Medicine and Surgery 36th Cycle, Department of BIOMORF, Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery 36th Cycle, Department of BIOMORF, Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Thanh N Nguyen
- Neurology, Boston Medical Center, MA, USA
- Radiology, Boston Medical Center, MA, USA
| | | | - Alina Buture
- Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Nicolas Raposo
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, "Attikon University Hospital", Athens, Greece
| | | | - Antonio Ciacciarelli
- Neurology Division, Santa Maria Goretti Hospital, Latina, Italy
- Department of Translation and Precision Medicine, Sapienza University of Rome, Italy
| | - Joshua Mbroh
- Department of Neurology & Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | | | - Pasquale Scoppettuolo
- Neurology Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria-IRCCS di Reggio Emilia, Italy
| | - Kateryna Antonenko
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Diana Aguiar de Sousa
- Lisbon Central University Hospital and Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Sven Poli
- Department of Neurology & Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - José M Ferro
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Heitkamp C, Winkelmeier L, Heit JJ, Albers GW, Lansberg MG, Kniep H, Broocks G, Stracke CP, Schell M, Guenego A, Paech D, Wintermark M, Fiehler J, Faizy TD. Early neurological deterioration in patients with acute ischemic stroke is linked to unfavorable cerebral venous outflow. Eur Stroke J 2024; 9:162-171. [PMID: 38069665 PMCID: PMC10916832 DOI: 10.1177/23969873231208277] [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: 07/06/2023] [Accepted: 09/29/2023] [Indexed: 03/06/2024] Open
Abstract
INTRODUCTION Early neurological deterioration (END) is associated with poor outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Causes of END after mechanical thrombectomy (MT) include unsuccessful recanalization and reperfusion hemorrhages. However, little is known about END excluding the aforementioned causes. We aimed to investigate factors associated with unexplained END (ENDunexplained) with regard to the cerebral collateral status. PATIENTS AND METHODS Multicenter retrospective study of AIS-LVO patients with successful MT (mTICI 2b-3). On admission CT angiography (CTA), pial arterial collaterals and venous outflow (VO) were assessed using the modified Tan-Scale and the Cortical Vein Opacification Score (COVES), respectively. ENDunexplained was defined as an increase in NIHSS score of ⩾ 4 within the first 24 hours after MT without parenchymal hemorrhage on follow-up imaging. Multivariable regression analyses were performed to examine factors of ENDunexplained and unfavorable functional outcome (modified Rankin Scale score 3-6). RESULTS A total of 620 patients met the inclusion criteria. ENDunexplained occurred in 10% of patients. While there was no significant difference in pial arterial collaterals, patients with ENDunexplained exhibited more often unfavorable VO (81% vs. 53%; P < 0.001). Unfavorable VO (aOR [95% CI]; 2.56 [1.02-6.40]; P = 0.045) was an independent predictor of ENDunexplained. ENDunexplained was independently associated with unfavorable functional outcomes at 90 days (aOR [95% CI]; 6.25 [2.06-18.94]; P = 0.001). DISCUSSION AND CONCLUSION Unfavorable VO on admission CTA was associated with ENDunexplained. ENDunexplained was independently linked to unfavorable functional outcomes at 90 days. Identifying AIS-LVO patients at risk of ENDunexplained may help to select patients for intensified monitoring and guide to optimal treatment regimes.
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Affiliation(s)
- Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Christian Paul Stracke
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Adrien Guenego
- Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
| | - Daniel Paech
- Clinic for Neuroradiology, University Hospital Bonn, Germany
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
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Yi L, Li Z, Jiang Y, Jiang Y, Meng X, Li H, Zhao X, Wang Y, Liu L, Wang Y, Gu H. Inflammatory marker profiles and in-hospital neurological deterioration in patients with acute minor ischemic stroke. CNS Neurosci Ther 2024; 30:e14648. [PMID: 38432871 PMCID: PMC10909616 DOI: 10.1111/cns.14648] [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: 10/11/2023] [Revised: 01/10/2024] [Accepted: 02/10/2024] [Indexed: 03/05/2024] Open
Abstract
AIM The aim of the study was to analyze the association between inflammatory marker profiles and in-hospital neurological deterioration (ND) in acute ischemic stroke (AIS) patients. METHODS Data from patients with minor AIS from the Third China National Stroke Registry were analyzed. Inflammatory cytokine levels within 24 h of admission were measured. The primary outcome was in-hospital ND (an increase in National Institutes of Health Stroke Scale score ≥4 from admission to discharge). Associations were evaluated using odds ratios (ORs) and 95% confidence intervals (CIs) derived from logistic regression models. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were used to evaluate incremental predictive values. RESULTS A total of 4031 patients (1246 women, 30.9%) with a median age of 62 years were included. In-hospital ND occurred in 121 patients (3%). Each standard-deviation increase in interleukin (IL)-6 (OR, 1.17 [95% CI, 1.06-1.31]) and high-sensitivity C-reactive protein (hsCRP) (OR, 1.43 [95% CI, 1.24-1.66]) levels was associated with increased in-hospital ND risk. Incremental predictive values for adding IL-6 (IDI, 0.012; NRI, 0.329) but not hsCRP levels to the conventional risk factors were found. CONCLUSION In minor AIS, hsCRP and IL-6 levels were associated with in-hospital ND, including IL-6 levels in prognostic models improved risk classification.
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Affiliation(s)
- Luo Yi
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Zi‐Xiao Li
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Ying‐Yu Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Xia Meng
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Xing‐Quan Zhao
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yi‐Long Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Li‐Ping Liu
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yong‐Jun Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Hong‐Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
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Pujara DK, Al-Shaibi F, Sarraj A. Is thrombectomy indicated in all ischemic stroke with large vessel occlusion? Curr Opin Neurol 2024; 37:8-18. [PMID: 38054587 DOI: 10.1097/wco.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
PURPOSE OF REVIEW Purpose of this topical review is to examine the current randomized and nonrandomized evidence evaluating endovascular thrombectomy (EVT) in selected patient populations with acute ischemic stroke due to large vessel occlusions. RECENT FINDINGS After establishing EVT as the first-line treatment in patients with large vessel occlusions and limited ischemic changes on neuroimaging, recent trials successfully demonstrated efficacy and safety in patients with large core strokes and those with basilar occlusions up to 24 h of last known well. Nonrandomized evidence in patients with mild stroke severity, baseline disability, medium and distal vessel occlusions and time from last known well >24 h also suggested potential benefit of EVT in selected patients. Further randomized evidence will help establish EVT efficacy and safety in these populations. SUMMARY EVT is established as the de-facto treatment of choice in a significant proportion of patients presenting with acute ischemic stroke due to a large vessel occlusion and has shown potential benefits in additional patient subgroups. A rigorous risk-benefit assessment and discussions with patients and their families in the absence of randomized evidence should help facilitate an informed, individualized decision-making process for this revolutionary treatment in peripheral patient subgroups with limited evidence.
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Affiliation(s)
| | - Faisal Al-Shaibi
- University Hospitals Neurological Institute
- Case Western Reserve University School of Medicine, Department of Neurology, Cleveland, Ohio, USA
- King Abdulaziz University, Department of Neurology, Jeddah, Saudi Arabia
| | - Amrou Sarraj
- University Hospitals Neurological Institute
- Case Western Reserve University School of Medicine, Department of Neurology, Cleveland, Ohio, USA
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Cucchiara B, Majersik JJ. The Case of Anticoagulation for Progressing Stroke: Have We Come Full Circle? JAMA Neurol 2024; 81:113-114. [PMID: 38190153 DOI: 10.1001/jamaneurol.2023.5086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Affiliation(s)
- Brett Cucchiara
- Department of Neurology, University of Pennsylvania, Philadelphia
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Abou Karam G, Chen MC, Zeevi D, Harms BC, Torres-Lopez VM, Rivier CA, Malhotra A, de Havenon A, Falcone GJ, Sheth KN, Payabvash S. Time-Dependent Changes in Hematoma Expansion Rate after Supratentorial Intracerebral Hemorrhage and Its Relationship with Neurological Deterioration and Functional Outcome. Diagnostics (Basel) 2024; 14:308. [PMID: 38337824 PMCID: PMC10855868 DOI: 10.3390/diagnostics14030308] [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: 01/11/2024] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Hematoma expansion (HE) following an intracerebral hemorrhage (ICH) is a modifiable risk factor and a treatment target. We examined the association of HE with neurological deterioration (ND), functional outcome, and mortality based on the time gap from onset to baseline CT. METHODS We included 567 consecutive patients with supratentorial ICH and baseline head CT within 24 h of onset. ND was defined as a ≥4-point increase on the NIH stroke scale (NIHSS) or a ≥2-point drop on the Glasgow coma scale. Poor outcome was defined as a modified Rankin score of 4 to 6 at 3-month follow-up. RESULTS The rate of HE was higher among those scanned within 3 h (124/304, 40.8%) versus 3 to 24 h post-ICH onset (53/263, 20.2%) (p < 0.001). However, HE was an independent predictor of ND (p < 0.001), poor outcome (p = 0.010), and mortality (p = 0.003) among those scanned within 3 h, as well as those scanned 3-24 h post-ICH (p = 0.043, p = 0.037, and p = 0.004, respectively). Also, in a subset of 180/567 (31.7%) patients presenting with mild symptoms (NIHSS ≤ 5), hematoma growth was an independent predictor of ND (p = 0.026), poor outcome (p = 0.037), and mortality (p = 0.027). CONCLUSION Despite decreasing rates over time after ICH onset, HE remains an independent predictor of ND, functional outcome, and mortality among those presenting >3 h after onset or with mild symptoms.
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Affiliation(s)
- Gaby Abou Karam
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06520, USA; (G.A.K.); (M.-C.C.); (D.Z.); (B.C.H.); (A.M.)
| | - Min-Chiun Chen
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06520, USA; (G.A.K.); (M.-C.C.); (D.Z.); (B.C.H.); (A.M.)
| | - Dorin Zeevi
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06520, USA; (G.A.K.); (M.-C.C.); (D.Z.); (B.C.H.); (A.M.)
| | - Bendix C. Harms
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06520, USA; (G.A.K.); (M.-C.C.); (D.Z.); (B.C.H.); (A.M.)
| | - Victor M. Torres-Lopez
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; (V.M.T.-L.); (C.A.R.); (A.d.H.); (G.J.F.); (K.N.S.)
| | - Cyprien A. Rivier
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; (V.M.T.-L.); (C.A.R.); (A.d.H.); (G.J.F.); (K.N.S.)
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06520, USA; (G.A.K.); (M.-C.C.); (D.Z.); (B.C.H.); (A.M.)
| | - Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; (V.M.T.-L.); (C.A.R.); (A.d.H.); (G.J.F.); (K.N.S.)
- Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; (V.M.T.-L.); (C.A.R.); (A.d.H.); (G.J.F.); (K.N.S.)
- Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; (V.M.T.-L.); (C.A.R.); (A.d.H.); (G.J.F.); (K.N.S.)
- Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Seyedmehdi Payabvash
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06520, USA; (G.A.K.); (M.-C.C.); (D.Z.); (B.C.H.); (A.M.)
- Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT 06520, USA
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Mao XL, He SS, Lin CD, Huang XD, Sun J. Analysis of Clinical Characteristics and Influencing Factors of Early Neurological Deterioration in Patients With Mild Stroke by Intravenous Alteplase Therapy. Neurologist 2024:00127893-990000000-00124. [PMID: 38251767 DOI: 10.1097/nrl.0000000000000553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES Thrombolysis treatment for patients with mild stroke is controversial. The aim of our study was to investigate the clinical characteristics and influencing factors of early neurological deterioration (END) in this group of patients. METHODS A retrospective analysis was performed on ischemic stroke patients with intravenous thrombolysis (IVT) in Wenzhou Central Hospital. Subgroup analyses were performed for the mild stroke group and nonmild stroke group, END group, and non-early neurological deterioration group in mild stroke patients, respectively. RESULTS A total of 498 patients were included in this study. Compared with the control group, the mild stroke group was younger age, less atrial fibrillation, previous history of stroke and less use of antithrombotic drugs, more dyslipidemia, smoking, and drinking. Small artery occlusion type was more common in mild stroke, cardioembolism and stroke of undetermined etiology type were less. In the mild stroke group, the symptomatic intracerebral hemorrhage (sICH) rate was 2.54%, and the END rate was 16.1%. Predictors of END included systolic blood pressure, blood glucose, cardioembolism subtype, sICH, and large vessel occlusion. In END patients, the sICH rate was 10.53%, and 84.21% of cases started to worsen within 12 hours after IVT. There was no statistically significant difference in the time to exacerbation among different subtypes. CONCLUSIONS The occurrence of mild stroke in young patients was largely related to unhealthy lifestyles. The incidence of END in mild stroke IVT patients was low, with most occurring within 12 hours of IVT. There were many risk factors for END: large vessel occlusion and hyperglycemia were independent risk factors for END after IVT. sICH was an important but rare risk factor for END.
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Affiliation(s)
- Xin-Lei Mao
- Department of Brain Center, Wenzhou Central Hospital, Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Luo B, Yuan M, Kuang W, Wang Y, Chen L, Zhang Y, Chen G. A novel nomogram predicting early neurological deterioration after intravenous thrombolysis for acute ischemic stroke. Heliyon 2024; 10:e23341. [PMID: 38163222 PMCID: PMC10757001 DOI: 10.1016/j.heliyon.2023.e23341] [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] [Received: 07/04/2023] [Revised: 08/17/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
Objectives Intravenous thrombolysis therapy (IVT) with recombinant tissue plasminogen activator has proven to be a beneficial treatment for acute ischemic stroke (AIS) patients when administered within 4.5 h after a stroke. This study aimed to investigate an available and inexpensive predictive tool for early neurological deterioration in AIS. Methods Patients admitted to our department with acute stroke who were given IVT with recombinant tissue plasminogen activator within 4.5 h of stroke onset were included in the study. The NIH stroke scale (NIHSS) was used to assess patients' neurological state prior to IVT and for 24 h after. Early neurological deterioration was defined as occurring if the NIHSS total score increased by ≥ 4 or the NIHSS individual score increased by ≥ 2 compared to baseline. Patients were randomly assigned to training or validation cohorts. Results Of the 266 AIS patients receiving IVT who were screened, 217 were deemed eligible for the study. Multivariate logistic regression analysis identified smoking history, NIHSS score, homocysteine level, and neutrophil to lymphocyte ratio as independent factors for predicting early neurological deterioration. ROC analysis was used to assess the quality of the resulting nomogram. The AUC for the training dataset was 0.826 (95 % CI, 0.719-0.932), and for the validation dataset was 0.887 (95 % CI, 0.763-1.000). Conclusion The robustness of this nomogram suggests that it may be a reliable tool for evaluating the progression of AIS after IVT.
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Affiliation(s)
- Bang Luo
- Department of Neurology, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
| | - Mei Yuan
- Department of Neurology, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
| | - Wending Kuang
- Department of Neurology, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
| | - Yuzheng Wang
- Department of Neurology, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
| | - Liucui Chen
- School of Pharmaceutical Science, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
| | - Yang Zhang
- Department of Neurology, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
| | - Gang Chen
- Department of Neurology, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, China
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10
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Qin B, Zhang Y, Liang S, Liang H, Tang S, Liang Z. Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:e475-e483. [PMID: 36813553 DOI: 10.1136/jnis-2022-019959] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The effectiveness of endovascular treatment (EVT) in patients with mild stroke (National Institutes of Health Stroke Scale score ≤5) and acute anterior circulation large vessel occlusion (AACLVO) remains unknown. OBJECTIVE To conduct a meta-analysis to compare the efficacy and safety of EVT in patients with mild stroke and AACLVO. METHODS EMBASE, Cochrane Library, PubMed, and Clinicaltrials.gov databases were searched until October 2022. Both retrospective and prospective studies which compared the clinical outcomes between EVT and medical treatment were included. ORs and 95% confidence intervals (CIs) for excellent and favorable functional outcomes, symptomatic intracranial hemorrhage (ICH), and mortality were pooled using a random-effects model. A propensity score (PS)-based methods adjusted analysis was also performed. RESULTS 4335 patients from 14 studies were included. In patients with mild stroke and AACLVO, EVT presented no marked differences in excellent and favorable functional outcomes and mortality compared with medical treatment. A higher risk of symptomatic ICH (OR=2.79; 95% CI 1.49 to 5.24; P=0.001) was observed with EVT. Subgroup analysis revealed that EVT had potential benefit for proximal occlusions with excellent functional outcomes (OR=1.68; 95% CI 1.01 to 2.82; P=0.05). Similar results were observed when PS-based methods adjusted analysis was used. CONCLUSION EVT did not significantly benefit clinical functional outcomes in comparison with medical treatment in patients with mild stroke and AACLVO. However, it may improve functional outcomes when treating patients with proximal occlusion, despite being associated with an increased risk of symptomatic ICH. Stronger evidence from ongoing randomized controlled trials is required.
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Affiliation(s)
- Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yunli Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shiting Tang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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11
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Broccolini A, Brunetti V, Colò F, Alexandre AM, Valente I, Falcou A, Frisullo G, Pedicelli A, Scarcia L, Scala I, Rizzo PA, Bellavia S, Camilli A, Milonia L, Piano M, Macera A, Commodaro C, Ruggiero M, Da Ros V, Bellini L, Lazzarotti GA, Cosottini M, Caragliano AA, Vinci SL, Gabrieli JD, Causin F, Panni P, Roveri L, Limbucci N, Arba F, Pileggi M, Bianco G, Romano DG, Frauenfelder G, Semeraro V, Ganimede MP, Lozupone E, Fasano A, Lafe E, Cavallini A, Russo R, Bergui M, Calabresi P, Della Marca G. Early neurological deterioration in patients with minor stroke due to isolated M2 occlusion undergoing medical management: a retrospective multicenter study. J Neurointerv Surg 2023; 16:38-44. [PMID: 36977569 DOI: 10.1136/jnis-2023-020118] [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: 01/23/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Patients with minor stroke and M2 occlusion undergoing best medical management (BMM) may face early neurological deterioration (END) that can lead to poor long-term outcome. In case of END, rescue mechanical thrombectomy (rMT) seems beneficial. Our study aimed to define factors relevant to clinical outcome in patients undergoing BMM with the possibility of rMT on END, and find predictors of END. METHODS Patients with M2 occlusion and a baseline National Institutes of Health Stroke Scale (NIHSS) score≤5 that received either BMM only or rMT on END after BMM were extracted from the databases of 16 comprehensive stroke centers. Clinical outcome measures were a 90-day modified Rankin Scale (mRS) score of 0-1 or 0-2, and occurrence of END. RESULTS Among 10 169 consecutive patients with large vessel occlusion admitted between 2016 and 2021, 208 patients were available for analysis. END was reported in 87 patients that were therefore all subjected to rMT. In a logistic regression model, END (OR 3.386, 95% CI 1.428 to 8.032), baseline NIHSS score (OR 1.362, 95% CI 1.004 to 1.848) and a pre-event mRS score=1 (OR 3.226, 95% CI 1.229 to 8.465) were associated with unfavorable outcome. In patients with END, successful rMT was associated with favorable outcome (OR 4.549, 95% CI 1.098 to 18.851). Among baseline clinical and neuroradiological features, presence of atrial fibrillation was a predictor of END (OR 3.547, 95% CI 1.014 to 12.406). CONCLUSION Patients with minor stroke due to M2 occlusion and atrial fibrillation should be closely monitored for possible worsening during BMM and, in this case, promptly considered for rMT.
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Affiliation(s)
- Aldobrando Broccolini
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Valerio Brunetti
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Andrea M Alexandre
- Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Iacopo Valente
- Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Anne Falcou
- Stroke Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Giovanni Frisullo
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Pedicelli
- Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Scarcia
- Catholic University School of Medicine, Rome, Italy
| | - Irene Scala
- Catholic University School of Medicine, Rome, Italy
| | | | | | | | - Luca Milonia
- Interventional Neuroradiology, University Hospital Policlinico Umberto I, Rome, Italy
| | - Mariangela Piano
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | - Valerio Da Ros
- Department of Biomedicine and Prevention, Fondazione PTV Policlinico 'Tor Vergata', Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, Fondazione PTV Policlinico 'Tor Vergata', Rome, Italy
| | - Guido A Lazzarotti
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Sergio L Vinci
- Neuroradiology Unit, AOU Policlinico G. Martino, Messina, Italy
| | - Joseph D Gabrieli
- Neuroradiology Unit, Policlinico Universitario di Padova, Padua, Italy
| | - Francesco Causin
- Neuroradiology Unit, Policlinico Universitario di Padova, Padua, Italy
| | - Pietro Panni
- Interventional Neuroradiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Luisa Roveri
- Neurology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Francesco Arba
- Stroke Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Marco Pileggi
- Neuroradiology Unit, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Giovanni Bianco
- Stroke Unit, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Daniele G Romano
- Neuroradiology Unit, AOU S. Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Giulia Frauenfelder
- Neuroradiology Unit, AOU S. Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Vittorio Semeraro
- Interventional Radiology Unit, "SS. Annunziata" Hospital, Taranto, Italy
| | | | | | | | - Elvis Lafe
- Neuroradiology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Cavallini
- Cerebrovascular Diseases Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | - Riccardo Russo
- Interventional Neuroradiology, Azienda Ospedaliero Universitaria Citta della Salute e della Scienza di Torino, Turin, Italy
| | - Mauro Bergui
- Interventional Neuroradiology, Azienda Ospedaliero Universitaria Citta della Salute e della Scienza di Torino, Turin, Italy
| | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Giacomo Della Marca
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
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12
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Li G, Sun Y, Liu T, Yang P, Peng Y, Chen W, Zhang L, Chu J, Kuai D, Wang Z, Wu W, Xu Y, Zhou B, Geng Y, Yin C, Li J, Wang M, Peng X, Xiao Y, Li M, Zhang X, Liu P, Wang N, Zhang Y. Predictive factors of poor outcome and mortality among anterior ischaemic stroke patients despite successful recanalisation in China: a secondary analysis of the CAPTURE trial. BMJ Open 2023; 13:e078917. [PMID: 38070920 PMCID: PMC10729217 DOI: 10.1136/bmjopen-2023-078917] [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] [Received: 08/16/2023] [Accepted: 11/02/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES This work aimed to analyse the risk factors for poor outcomes and mortality among patients with anterior large vessel occlusion (LVO) ischaemic stroke, despite successful recanalisation. SETTING AND PARTICIPANTS This study conducted a secondary analysis among patients who underwent successful recanalisation in the CAPTURE trial. The trial took place between March 2018 and September 2020 at 21 sites in China. The CAPTURE trial enrolled patients who had an acute ischaemic stroke aged 18-80 years with LVO in anterior circulation. INTERVENTIONS Thrombectomy was immediately performed using Neurohawk or the Solitaire FR after randomisation in CAPTURE trial. Rescue treatment was available for patients with severe residual stenosis caused by atherosclerosis. PRIMARY AND SECONDARY OUTCOME MEASURES The primary goal was to predict poor 90-day survival or mortality within 90 days post-thrombectomy. Univariate analysis, using the χ2 test or Fisher's exact test, was conducted for each selected factor. Subsequently, a multivariable analysis was performed on significant factors (p≤0.10) identified through univariate analysis using the backward selection logistic regression approach. RESULTS Among the 207 recruited patients, 79 (38.2%) exhibited poor clinical outcomes, and 26 (12.6%) died within 90 days post-thrombectomy. Multivariate analysis revealed that the following factors were significantly associated with poor 90-day survival: age ≥67 years, internal carotid artery (ICA) occlusion (compared with middle cerebral artery (MCA) occlusion), initial National Institutes of Health Stroke Scale (NIHSS) score ≥17 and final modified Thrombolysis in Cerebral Infarction (mTICI) score 2b (compared with mTICI 3). Additionally, the following factors were significantly associated with mortality 90 days post-thrombectomy: initial NIHSS score ≥17, ICA occlusion (compared with MCA occlusion) and recanalisation with more than one pass. CONCLUSIONS Age, NIHSS score, occlusion site, mTICI score and the number of passes can be independently used to predict poor 90-day survival or mortality within 90 days post-thrombectomy. TRIAL REGISTRATION NUMBER NCT04995757.
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Affiliation(s)
- Guangwen Li
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yujie Sun
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tonghui Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Ya Peng
- Department of Neurosurgery, Changzhou First People's Hospital, Changzhou, Jiangsu, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Hospital Affiliated to Fujian Medical University, Zhangzhou, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital Brain Hospital, Liaocheng, Shandong, China
| | - Jianfeng Chu
- Department of Neurology, The First People's Hospital of Jining City, Jining, China
| | - Dong Kuai
- Department of Neurosurgery, Shanxi Provincial Cardiovascular Hospital, Taiyuan, China
| | - Zibo Wang
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yun Xu
- Department of Neurology, Nanjing Gulou Hospital, Nanjing, China
| | - Bin Zhou
- Department of Neurointervention, Cerebrovascular Disease Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
| | - Jiang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Military Medical University, Xi'an, China
| | - Ming Wang
- Department of Neurointervention, Nanyang Second People's Hospital, Nanyang, China
| | - Xiaoxiang Peng
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Yaping Xiao
- Department of Neurology, Shanghai Oriental Hospital, Shanghai, China
| | - Minghua Li
- Institute of Diagnostic and Interventional Neuroradiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xianjun Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Peng Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Naidong Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yong Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
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13
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Palazzo P, Padlina G, Dobrocky T, Strambo D, Seners P, Mechtouff L, Turc G, Rosso C, Almiri W, Antonenko K, Laksiri N, Sibon I, Detante O, Mordasini P, Michel P, Heldner MR. Relevance of National Institutes of Health Stroke Scale subitems for best revascularization therapy in minor stroke patients with large vessel occlusion: An observational multicentric study. Eur J Neurol 2023; 30:3741-3750. [PMID: 37517048 DOI: 10.1111/ene.16009] [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: 04/30/2023] [Revised: 06/30/2023] [Accepted: 07/27/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND AND PURPOSE The best management of acute ischemic stroke patients with a minor stroke and large vessel occlusion is still uncertain. Specific clinical and radiological data may help to select patients who would benefit from endovascular therapy (EVT). We aimed to evaluate the relevance of National Institutes of Health Stroke Scale (NIHSS) subitems for predicting the potential benefit of providing EVT after intravenous thrombolysis (IVT; "bridging treatment") versus IVT alone. METHODS We extracted demographic, clinical, risk factor, radiological, revascularization and outcome data of consecutive patients with M1 or proximal M2 middle cerebral artery occlusion and admission NIHSS scores of 0-5 points, treated with IVT ± EVT between May 2005 and March 2021, from nine prospectively constructed stroke registries at seven French and two Swiss comprehensive stroke centers. Adjusted interaction analyses were performed between admission NIHSS subitems and revascularization modality for two primary outcomes at 3 months: non-excellent functional outcome (modified Rankin Scale score 2-6) and difference in NIHSS score between 3 months and admission. RESULTS Of the 533 patients included (median age 68.2 years, 46% women, median admission NIHSS score 3), 136 (25.5%) initially received bridging therapy and 397 (74.5%) received IVT alone. Adjusted interaction analysis revealed that only facial palsy on admission was more frequently associated with excellent outcome in patients treated by IVT alone versus bridging therapy (odds ratio 0.47, 95% confidence interval 0.24-0.91; p = 0.013). Regarding NIHSS difference at 3 months, no single NIHSS subitem interacted with type of revascularization. CONCLUSIONS This retrospective multicenter analysis found that NIHSS subitems at admission had little value in predicting patients who might benefit from bridging therapy as opposed to IVT alone. Further research is needed to identify better markers for selecting EVT responders with minor strokes.
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Affiliation(s)
- Paola Palazzo
- Department of Clinical Neurosciences, Neurology Service, Stroke Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Giovanna Padlina
- Stroke Research Center Bern, Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Davide Strambo
- Department of Clinical Neurosciences, Neurology Service, Stroke Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Seners
- Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France
| | | | - Guillaume Turc
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris and Department of Neurology, GHU Paris Psychiatrie et Neurosciences Inserm U1266, Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Charlotte Rosso
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière (ICM) and APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - William Almiri
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Kateryna Antonenko
- Stroke Research Center Bern, Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Nadia Laksiri
- Neurology Department, La Timone University Hospital, Marseille, France
| | - Igor Sibon
- Department of Neurology, Stroke Unit, CHU Bordeaux, Bordeaux, France
| | - Olivier Detante
- Neurology Department, Stroke Unit, Inserm U1216, CHU Grenoble Alpes, University Grenoble Alpes, Grenoble Institut des Neurosciences, Grenoble, France
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Department of Neuroradiology, St. Gallen Kantonsspital, St. Gallen, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Neurology Service, Stroke Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Mirjam R Heldner
- Stroke Research Center Bern, Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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14
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Arquizan C, Lapergue B, Gory B, Labreuche J, Henon H, Albucher JF, Sibon I, Turc G, Richard S, Nouri N, Cognard C, Marnat G, Naggara O, Di Maria F, Duhamel A, Jovin T, Costalat V. Evaluation of acute mechanical revascularization in minor stroke (NIHSS score ⩽ 5) and large vessel occlusion: The MOSTE multicenter, randomized, clinical trial protocol. Int J Stroke 2023; 18:1255-1259. [PMID: 37350574 DOI: 10.1177/17474930231186039] [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] [Indexed: 06/24/2023]
Abstract
RATIONALE Mechanical thrombectomy (MT) has become the standard of care for patients with acute ischemic stroke secondary to large vessel occlusion (LVO) of the anterior circulation. Conversely, its benefit in patients with National Institutes of Health Stroke Scale (NIHSS) score ⩽ 5 is unproven. AIM To demonstrate the superiority of immediate MT plus best medical treatment (BMT) compared to BMT (with secondary MT in case of deterioration) for increasing the rate of modified Rankin Scale (mRS) score ⩽ 1 at 90 days after minor stroke (NIHSS score ⩽ 5) and anterior circulation LVO. SAMPLE SIZE ESTIMATES To detect an absolute increase of 10% (80% power) in the 90-day mRS score = 0-1 rate in the MT + BMT group, by assuming an mRS score = 0-1 rate of 60% in the BMT group and by considering two interim efficacy/futility analyses (after study completion by 274 and 548 patients), 824 patients must be included by 36 centers in France, Spain, and the USA. METHODS AND DESIGN MOSTE is an international, multicenter, prospectively randomized into two parallel (1:1) arms, open-label, with blinded endpoint trial. Eligibility criteria are diagnosis of acute ischemic stroke within 23 h of last-seen-well, NIHSS score ⩽ 5, and LVO in the anterior circulation (intracranial internal carotid artery, M1 or M1-M2 segment of the middle cerebral artery). STUDY OUTCOMES The primary endpoint is the rate of excellent outcome at day 90 (mRS score = 0-1). Secondary endpoints include the rates of 90-day mRS score = 0-2 and score = 0, NIHSS score change, secondary MT, revascularization and infarct volume growth at 24 h, and quality of life and cognitive function at day 90. Safety outcomes (90-day all-cause mortality, procedural complications, symptomatic intracerebral hemorrhage, and rapid NIHSS score worsening) are recorded. DISCUSSION The MOSTE trial will determine MT efficacy and safety in patients with minor stroke and LVO in the anterior circulation. TRIAL REGISTRATION MOSTE Trial. NCT03796468.
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Affiliation(s)
- Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France
- INSERM U1266, Paris, France
| | | | - Benjamin Gory
- Department of Neuroradiology, Hôpital Central, Nancy, France
- IADI, INSERM U1254, Nancy, France
| | - Julien Labreuche
- Department of Biostatistics, Lille University Hospital, Lille, France
| | - Hilde Henon
- Department of Neurology, Hôpital Salengro, Lille, France
| | | | - Igor Sibon
- Department of Neurology, Hôpital Pellegrin, Bordeaux, France
| | - Guillaume Turc
- INSERM U1266, Paris, France
- Department of Neurology, Hôpital Sainte-Anne, Paris, France
| | | | | | - Christophe Cognard
- Department of Neuroradiology, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Gauthier Marnat
- Department of Neuroradiology, Hôpital Pellegrin, Bordeaux, France
| | - Olivier Naggara
- INSERM U1266, Paris, France
- Department of Neuroradiology, Hôpital Sainte-Anne, Paris, France
| | | | - Alain Duhamel
- Department of Biostatistics, Lille University Hospital, Lille, France
| | - Tudor Jovin
- Cooper Neurological Institute, Camden, NJ, USA
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
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15
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Tian T, Wang L, Xu J, Jia Y, Xue K, Huang S, Shen T, Luo Y, Li S, Min L. Prediction of early neurological deterioration in acute ischemic stroke patients treated with intravenous thrombolysis. J Cereb Blood Flow Metab 2023; 43:2049-2059. [PMID: 37668997 PMCID: PMC10925869 DOI: 10.1177/0271678x231200117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/06/2023] [Accepted: 08/13/2023] [Indexed: 09/06/2023]
Abstract
A proportion of acute ischemic stroke (AIS) patients suffer from early neurological deterioration (END) within 24 hours following intravenous thrombolysis (IVT), which greatly increases the risk of poor prognosis of these patients. Therefore, we aimed to explore the predictors of early neurological deterioration of ischemic origin (ENDi) in AIS patients after IVT and develop a nomogram prediction model. This study collected 244 AIS patients with post-thrombolysis ENDi as the derivation cohort and 155 patients as the validation cohort. To establish a nomogram prediction model, risk factors were identified by multivariate logistic regression analysis. The results showed that neutrophil to lymphocyte ratio (NLR) (OR 2.616, 95% CI 1.640-4.175, P < 0.001), mean platelet volume (MPV) (OR 3.334, 95% CI 1.351-8.299, P = 0.009), body mass index (BMI) (OR 1.979, 95% CI 1.285-3.048, P = 0.002) and atrial fibrillation (AF) (OR 8.012, 95% CI 1.341-47.873, P = 0.023) were significantly associated with ENDi. The area under the curve of the prediction model constructed from the above four factors was 0.981 (95% CI 0.961-1.000) and the calibration curve was close to the ideal diagonal line. Therefore, this nomogram prediction model exhibited good discrimination and calibration power and might be a reliable and easy-to-use tool to predict post-thrombolysis ENDi in AIS patients.
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Affiliation(s)
- Tian Tian
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Lanjing Wang
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiali Xu
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yujie Jia
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Kun Xue
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Shuangfeng Huang
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tong Shen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yumin Luo
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Lianqiu Min
- Department of Neurology, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
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Cappellari M, Pracucci G, Saia V, Fainardi E, Casetta I, Sallustio F, Ruggiero M, Longoni M, Simonetti L, Zini A, Lazzarotti GA, Giannini N, Da Ros V, Diomedi M, Vallone S, Bigliardi G, Limbucci N, Nencini P, Ajello D, Marcheselli S, Burdi N, Boero G, Bracco S, Tassi R, Boghi A, Naldi A, Biraschi F, Nicolini E, Castellan L, Del Sette M, Allegretti L, Sugo A, Buonomo O, Dell'Aera C, Saletti A, De Vito A, Lafe E, Mazzacane F, Bergui M, Cerrato P, Feraco P, Piffer S, Augelli R, Vit F, Gasparotti R, Magoni M, Comelli S, Melis M, Menozzi R, Scoditti U, Cavasin N, Critelli A, Causin F, Baracchini C, Guzzardi G, Tarletti R, Filauri P, Orlandi B, Giorgianni A, Cariddi LP, Piano M, Motto C, Gallesio I, Sepe FN, Romano G, Grasso MF, Pauciulo A, Rizzo A, Comai A, Franchini E, Sicurella L, Galvano G, Mannino M, Mangiafico S, Toni D, On Behalf Of The Iretas Group. IV thrombolysis plus thrombectomy versus IV thrombolysis alone for minor stroke with anterior circulation large vessel occlusion from the IRETAS and Italian SITS-ISTR cohorts. Neurol Sci 2023; 44:4401-4410. [PMID: 37458843 DOI: 10.1007/s10072-023-06948-w] [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: 01/10/2023] [Accepted: 07/04/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The aim of this study was to compare the outcomes of patients treated with intravenous thrombolysis (IVT) <4.5 h after symptom onset plus mechanical thrombectomy (MT) <6 h with those treated with IVT alone <4.5 h for minor stroke (NIHSS ≤5) with large vessel occlusion (LVO) in the anterior circulation. PATIENTS AND METHODS Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analyzed. RESULTS Among the patients with complete data on 24-h ICH type, 236 received IVT plus MT and 382 received IVT alone. IVT plus MT was significantly associated with unfavorable shift on 24-h ICH types (from no ICH to PH-2) (OR, 2.130; 95% CI, 1.173-3.868; p=0.013) and higher rate of PH (OR, 4.363; 95% CI, 1.579-12.055; p=0.005), sICH per ECASS II definition (OR, 5.527; 95% CI, 1.378-22.167; p=0.016), and sICH per NINDS definition (OR, 3.805; 95% CI, 1.310-11.046; p=0.014). Among the patients with complete data on 3-month mRS score, 226 received IVT plus MT and 262 received IVT alone. No significant difference was reported between IVT plus MT and IVT alone on mRS score 0-1 (72.1% versus 69.1%), mRS score 0-2 (79.6% versus 79%), and death (6.2% versus 6.1%). CONCLUSIONS Compared with IVT alone, IVT plus MT was associated with unfavorable shift on 24-h ICH types and higher rate of 24-h PH and sICH in patients with minor stroke and LVO in the anterior circulation. However, no difference was reported between the groups on 3-month functional outcome measures.
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Affiliation(s)
- Manuel Cappellari
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy.
| | - Giovanni Pracucci
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Valentina Saia
- Neurology and Stroke Unit, S. Corona Hospital, Pietra Ligure, Italy
| | - Enrico Fainardi
- Dipartimento di Scienze Biomediche, Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi, Firenze, Italy
| | - Ilaria Casetta
- Neurology Unit, University Hospital Arcispedale S. Anna, Ferrara, Italy
| | - Fabrizio Sallustio
- Unitá di Trattamento Neurovascolare, Ospedale dei Castelli-ASL6, Rome, Italy
| | - Maria Ruggiero
- Neuroradiologia, AUSL Romagna Ospedale Bufalini, Cesena, Italy
| | - Marco Longoni
- Neurologia e Stroke Unit Ospedale Bufalini Cesena, AUSL Romagna, Ravenna, Italy
| | - Luigi Simonetti
- UO Neuroradiologia Ospedale Maggiore-IRCCS Istituto di Scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto di Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | | | - Nicola Giannini
- Neurological Institute, University Hospital of Pisa, Pisa, Italy
| | - Valerio Da Ros
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Nicola Limbucci
- Neurovascular Interventional Unit-Careggi University Hospital, Firenze, Italy
| | - Patrizia Nencini
- Stroke Unit, Azienda Ospedaliero Univarsitaria Careggi, Firenze, Italy
| | - Daniele Ajello
- Neuroradiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Nicola Burdi
- Neuroradiology, SS. Annunziata Hospital, Taranto, Italy
| | | | - Sandra Bracco
- Neuroradiologia interventistica, Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | - Rossana Tassi
- Stroke Unit, Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | - Andrea Boghi
- SC Radiologia e Neuroradiologia, Ospedale San Giovanni Bosco, Torino, Italy
| | - Andrea Naldi
- S.C. Neurologia 2 Ospedale San Giovanni Bosco, Torino, Italy
| | - Francesco Biraschi
- Department of Human Neurosciences, Interventional Neuroradiology, Universita degli Studi di Roma Sapienza, Rome, Lazio, Italy
| | - Ettore Nicolini
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Lucio Castellan
- Department of Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Massimo Del Sette
- Neurology and Stroke Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Luca Allegretti
- Department of Neuroradiology, S. Corona Hospital, Pietra Ligure, Italy
| | - Annalisa Sugo
- Neurology and Stroke Unit, S. Corona Hospital, Pietra Ligure, Italy
| | - Orazio Buonomo
- Neuroradiology Unit, Department of Biomedical, Dental, Morphological and Functional Imaging Sciences-University of Messina, Messina, Italy
| | - Cristina Dell'Aera
- Stroke Unit, Department of Clinical and Experimental Medicine-University of Messina, Messina, Italy
| | - Andrea Saletti
- Servizio di Neuroradiologia, Arcispedale S. Anna-University Hospital, Ferrara, Italy
| | - Alessandro De Vito
- Neurology Division-Stroke Unit, Arcispedale S. Anna-University Hospital, Ferrara, Italy
| | - Elvis Lafe
- UOC Radiologia Diagnostica per Immagini 2-Neuroradiologia, Policlinico IRCCS San Matteo, Pavia, Italy
| | - Federico Mazzacane
- UO Neurologia d'Urgenza e Stroke Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | - Mauro Bergui
- Università Torino Dipartimento Neuroscienze, Città della Salute e della Scienza-Molinette, Torino, Italy
| | - Paolo Cerrato
- Stroke Unit, Città della Salute e della Scienza-Molinette, Torino, Italy
| | - Paola Feraco
- U.O.C. Neuroradiologia diagnostica e Radiologia Interventistica, Ospedale Santa Chiara, Trento, Italy
| | - Silvio Piffer
- U.O.C Neurologia, Ospedale Santa Chiara, APSS di Trento, Trento, Italy
| | - Raffaele Augelli
- Neuroradiology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Federica Vit
- Stroke Unit, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy
| | | | | | - Simone Comelli
- Vascular and Interventional Neuroradiology Department, ARNAS G. Brotzu, Cagliari, Italy
| | - Maurizio Melis
- Neuroscience Department, ARNAS G. Brotzu, Cagliari, Italy
| | | | | | - Nicola Cavasin
- Neuroradiology Unit, Ospedale dell'Angelo, USSL 3 Serenissima, Mestre, Venice, Italy
| | - Adriana Critelli
- Neurology Unit, Ospedale dell'Angelo, USSL 3 Serenissima, Mestre, Venice, Italy
| | - Francesco Causin
- Department of Diagnostic Imaging and Interventional Radiology, Neuroradiology, Padua University Hospital, Padua, Italy
| | - Claudio Baracchini
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, University of Padua School of Medicine, Padua, Italy
| | | | | | - Pietro Filauri
- UOSD Radiologia interventistica, p.o., Avezzano, AQ, Italy
| | | | - Andrea Giorgianni
- UOC Neuroradiologia, ASST Sette Laghi Varese-Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | | | - Mariangela Piano
- Interventional Neuroradiology Unit, Ospedale Niguarda, Milan, Italy
| | | | - Ivan Gallesio
- Neuroradiology Unit AO "SS. Antonio e Biagio e C. Arrigo", Alessandria, Italy
| | | | | | | | | | - Annalisa Rizzo
- Department of Neurology, Vito Fazzi Hospital, Lecce, Italy
| | - Alessio Comai
- Neuroradiologia, Ospedale Provinciale di Bolzano, Bolzano, Italy
| | | | | | | | | | - Salvatore Mangiafico
- IRCCS Neuromed, Pozzilli, IS, Italy
- Tor Vergata University, Rome, Italy
- Sapienza University, Rome, Italy
- S. Andrea Hospital, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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Wu K, Yuan Z, Chen W, Yi T, Chen X, Ma M, Guo J, Zhou M, Chen N, He L. A nomogram predicts early neurological deterioration after mechanical thrombectomy in patients with ischemic stroke. Front Neurol 2023; 14:1255476. [PMID: 37799278 PMCID: PMC10548384 DOI: 10.3389/fneur.2023.1255476] [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: 07/08/2023] [Accepted: 08/21/2023] [Indexed: 10/07/2023] Open
Abstract
Introduction Early neurological deterioration (END) is common in acute ischemic stroke and is directly associated with poor outcome after stroke. Our aim is to develop and validate a nomogram to predict the risk of END after mechanical thrombectomy (MT) in acute ischemic stroke patients with anterior circulation large-vessel occlusion. Methods We conducted a real-world, multi-center study in patients with stroke treated with mechanical thrombectomy. END was defined as a worsening by 2 or more NIHSS points within 72-hour after stroke onset compared to admission. Multivariable logistic regression was used to determine the independent predictors of END, and the discrimination of the scale was assessed using the C-index. Calibration curves were constructed to evaluate the calibration of the nomogram, and decision curves were used to describe the benefits of using the nomogram. Results A total of 1007 patients were included in our study. Multivariate logistic regression analysis found age, admission systolic blood pressure, initial NIHSS scores, history of hyperlipemia, and location of occlusion were independent predictors of END. We developed a nomogram that included these 6 factors, and it revealed a prognostic accuracy with a C-index of 0.678 in the derivation group and 0.650 in the validation group. The calibration curves showed that the nomogram provided a good fit to the data, and the decision curves demonstrated a large net benefit. Discussion Our study established and validated a nomogram to stratify the risk of END before mechanical embolectomy and identify high-risk patients, who should be more cautious when making clinical decisions.
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Affiliation(s)
- Kongyuan Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhengzhou Yuan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Xiwen Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Muke Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ning Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Meyer L, Politi M, Alexandrou M, Roth C, Kastrup A, Mpotsaris A, Hanning U, Flottmann F, Brekenfeld C, Deb-Chatterji M, Thomalla G, Kniep H, Faizy TD, Bechstein M, Broocks G, Herzberg M, Feil K, Kellert L, Dorn F, Zeleňák K, Fiehler J, Papanagiotou P. Endovascular treatment of acute tandem lesions in patients with mild anterior circulation stroke. J Neurointerv Surg 2023; 15:e136-e141. [PMID: 36028317 DOI: 10.1136/jnis-2022-019239] [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: 06/03/2022] [Accepted: 08/06/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND In patients with mild strokes the risk-benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice. METHODS Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH). RESULTS A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59-76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2-5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8-10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1-9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5). CONCLUSIONS EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
- Interventional Radiology Unit, Evangelismos General Hospital, Athens, Greece
| | - Maria Alexandrou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Christian Roth
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Anastasios Mpotsaris
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moriz Herzberg
- Department of Radiology, University Hospital Würzburg, Würzburg, Germany
- Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
| | - Katharina Feil
- Department of Neurology, Ludwig Maximilians Universität, München, Germany
- Department of Neurology and Stroke, Eberhard-Karls University, Tübingen, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians Universität, München, Germany
| | - Franziska Dorn
- Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Kamil Zeleňák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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19
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Seners P, Cereda CW. Thrombectomy in Stroke With a Large Vessel Occlusion and Mild Symptoms: "Striving to Better, Oft We Mar What's Well?". Stroke 2023; 54:2276-2278. [PMID: 37526012 DOI: 10.1161/strokeaha.123.044205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Pierre Seners
- Stanford Stroke Center, Palo Alto, CA (P.S.)
- Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France (P.S.)
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM, Paris, France (P.S.)
| | - Carlo W Cereda
- Stroke Center EOC, Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano (C.W.C.)
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland (C.W.C.)
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Sykora M, Krebs S, Miksova D, Badic I, Gattringer T, Fandler-Höfler S, Marko M, Greisenegger S, Knoflach M, Lang W, Ferrari J. IV Thrombolysis vs Early Dual Antiplatelet Therapy in Patients With Mild Noncardioembolic Ischemic Stroke. Neurology 2023; 101:e933-e939. [PMID: 37407270 PMCID: PMC10501095 DOI: 10.1212/wnl.0000000000207538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/04/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND OBJECTIVES It is unclear whether IV thrombolysis (IVT) outperforms early dual antiplatelet therapy (DAPT) in the acute setting of mild ischemic stroke. The aim of this study was to compare the early safety and efficacy of IVT with that of DAPT. METHODS Data of mild noncardioembolic stroke patients with admission NIH Stroke Scale (NIHSS) score ≤3 who received IVT or early DAPT in the period 2018-2021 were extracted from a nationwide, prospective stroke unit registry. Study endpoints included symptomatic intracerebral hemorrhage (sICH), early neurologic deterioration ≥4 NIHSS points (END), and 3-month functional outcome by modified Rankin scale (mRS). RESULTS A total of 1,195 mild stroke patients treated with IVT and 2,625 patients treated with DAPT were included. IVT patients were younger (68.1 vs 70.8 years), had less hypertension (72.8% vs 83.5%), diabetes (19% vs 28.8%), and a history of myocardial infarction (7.6% vs 9.2%), and slightly higher admission NIHSS scores (median 2 vs median 1) when compared with DAPT patients. After propensity score matching and multivariable adjustment, IVT was associated with sICH (4 [1.2%] vs 0) and END (adjusted odds ratio [aOR] 2.8, 95% CI 1.1-7.5), and there was no difference in mRS 0-1 at 3 months (aOR 1.3, 95% CI 0.7-2.6). DISCUSSION This analysis from a prospective nationwide stroke unit network indicates that IVT is not superior to DAPT in the setting of mild noncardioembolic stroke and may eventually be associated with harm. Further research focusing on acute therapy of mild stroke is highly warranted. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that IVT is not superior to DAPT in patients with acute mild (NIHSS score ≤3) noncardioembolic stroke. The study lacks the statistical precision to exclude clinically important superiority of either therapy.
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Affiliation(s)
- Marek Sykora
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria.
| | - Stefan Krebs
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Dominika Miksova
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Ines Badic
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Thomas Gattringer
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Simon Fandler-Höfler
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Martha Marko
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Stefan Greisenegger
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Michael Knoflach
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Wilfried Lang
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
| | - Julia Ferrari
- From the Department Neurology (M.S., S.K., W.L., J.F.), St. Johns Hospital Vienna; Sigmund Freud University Vienna (M.S., I.B., W.L.); Austrian National Public Health Institute (D.M.), Vienna; Medical University of Graz (T.G., S.F.-H.); Medical University of Vienna (M.M., S.G.); and Medical University of Innsbruck (M.K.), Austria
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21
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Zhu Y, Lu Y, Mo Y, Zhang J, Yin X, Lin J, Li X, Liang H, Li Y, Wang Y, Yang X, Shang T, Li H, Hu Z. Associations of sedentary behaviors with mental health outcomes in a cohort of patients with minor ischemic stroke. J Psychosom Res 2023; 183:111463. [PMID: 38823370 DOI: 10.1016/j.jpsychores.2023.111463] [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: 02/11/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 06/03/2024]
Abstract
OBJECTIVE The relationship between sedentary behaviors and functional outcomes of acute ischemic stroke (AIS) has been previously reported. However, it remains unclear whether sedentary behaviors are associated with mental health outcomes in AIS patients. Therefore, the objective of this study was to investigate the mental health outcomes in patients with minor AIS one year after stroke onset. METHODS This cross-sectional study recruited 1230 patients with minor AIS (NIHSS ≤ 5) from three hospitals in China. One year after discharge, patients were interviewed using face-to-face questionnaires, including the PHQ-9, GAD-7, and ISI, to assess symptoms of depression, anxiety, and insomnia, respectively. Participants were categorized into the long sedentary time group and the short sedentary time group based on the median sedentary time of all participants. The associations between leisure sedentary time and mental health outcomes were investigated. RESULTS Participants with a long leisure sedentary time had higher PHQ-9, GAD-7, and ISI scores than those with a short sedentary time. Longer sedentary time was associated with an increased risk of experiencing symptoms of major depression (RR, 95% CI: 1.79, 1.47 to 2.18), anxiety (RR, 95% CI: 3.28, 2.08 to 5.18), and insomnia (RR, 95% CI: 2.58, 2.03 to 3.28) one year after a minor AIS. CONCLUSION Excessive sedentary time is associated with long-term mental health conditions after stroke. Therefore, reducing the sedentary time might be helpful for preventing poststroke depression, anxiety, and insomnia.
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Affiliation(s)
- Yongping Zhu
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yi Lu
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yongbiao Mo
- Department of Emergency, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Jun Zhang
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Xiang Yin
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Jie Lin
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Xuelian Li
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Hongtao Liang
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yongyong Li
- Department of Gerontology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Wang
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Yang
- Neuroscience Center, General Hospital of Ningxia Medical University, Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia, Yinchuan, China
| | - Tingting Shang
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haihua Li
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China.
| | - Zicheng Hu
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China; Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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22
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Riegler C, von Rennenberg R, Bollweg K, Nguyen TN, Kleine JF, Tiedt S, Audebert HJ, Siebert E, Nolte CH. Endovascular therapy in patients with internal carotid artery occlusion and patent circle of Willis. J Neurointerv Surg 2023:jnis-2023-020556. [PMID: 37491381 DOI: 10.1136/jnis-2023-020556] [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: 05/10/2023] [Accepted: 06/24/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Occlusion of the internal carotid artery (ICA) may extend into the middle or anterior cerebral artery (ICA-T) or be confined to the intracranial (ICA-I) or extracranial segment (ICA-E). While there is excellent evidence for endovascular therapy (EVT) in ICA-T occlusions, studies on EVT in non-tandem ICA-I or ICA-E occlusions are scarce. OBJECTIVE To characterize EVT-treated patients with ICA-I- and ICA-E occlusion by comparing them with ICA-T occlusions. METHODS The German Stroke Registry (GSR), a national, multicenter, prospective registry was searched for EVT-treated patients with isolated ICA occlusion between June 2015 and December 2021. We stratified patients by ICA occlusion site: (a) ICA-T, (b) ICA-I, (c) ICA-E. Baseline factors, procedural variables, technical (modified Thrombolysis in Cerebral Infarction (mTICI)), and functional outcomes (modified Rankin scale score at 3 months) were analyzed. RESULTS Of 13 082 GSR patients, 2588 (19.8%) presented with an isolated ICA occlusion, thereof 1946 (75.2%) ICA-T, 366 (14.1%) ICA-I, and 276 (10.7%) ICA-E patients. The groups differed in age (77 vs 76 vs 74 years, Ptrend=0.02), sex (53.4 vs 48.9 vs 43.1% female, Ptrend<0.01), and stroke severity (median National Institutes of Health Stroke Scale score at admission 17 vs 14 vs 13 points, Ptrend<0.001). In comparison with ICA-T occlusions, both ICA-I and ICA-E occlusions had lower rates of successful recanalization (mTICI 2b/3: 85.4% vs 80.4% vs 76.3%; aOR (95% CI for ICA-I vs ICA-T 0.71 (0.53 to 0.95); aOR (95% CI) for ICA-E vs ICA-T 0.57 (0.42 to 0.78)). In adjusted analyses, ICA-E occlusion was associated with worse outcome when compared with ICA-T occlusion (mRS ordinal shift, cOR (95% CI) 0.70 (0.52 to 0.93)). CONCLUSION Patient characteristics and outcomes differ substantially between ICA-T, ICA-I, and ICA-E occlusions. These results warrant further studies on EVT in ICA-I and ICA-E patients.
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Affiliation(s)
- Christoph Riegler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Regina von Rennenberg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Kerstin Bollweg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Justus F Kleine
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Heinrich J Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
- Berlin Insititute of Health at Charité, Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
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23
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Braadt L, Naumann M, Freuer D, Schmitz T, Linseisen J, Ertl M. Novel inflammatory biomarkers associated with stroke severity: results from a cross-sectional stroke cohort study. Neurol Res Pract 2023; 5:31. [PMID: 37468969 DOI: 10.1186/s42466-023-00259-3] [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: 04/04/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Stroke is a leading cause of mortality and disability worldwide and its occurrence is expected to increase in the future. Blood biomarkers have proven their usefulness in identification and monitoring of the disease. Stroke severity is a major factor for estimation of prognosis and risk of recurrent events, but knowledge on respective blood biomarkers is still scarce. Stroke pathophysiology comprises a multitude of ischemia-induced inflammatory and immune mediated responses. Therefore, the assessment of an immune-related panel in correlation with stroke severity seems promising. METHODS In the present cross-sectional evaluation, a set of 92 blood biomarkers of a standardized immune panel were gathered (median 4.6 days after admission) and related to stroke severity measures, assessed at hospital admission of acute stroke patients. Multivariable logistic regression models were used to determine associations between biomarkers and modified Rankin Scale (mRS), linear regression models were used for associations with National Institute of Health Stroke Scale. RESULTS 415 patients (mean age 69 years; 41% female) were included for biomarker analysis. C-type lectin domain family 4 member G (CLEC4G; OR = 2.89, 95% CI [1.49; 5.59], padj = 0.026, Cytoskeleton-associated protein 4 (CKAP4; OR = 2.38, 95% CI [1.43; 3.98], padj = 0.019), and Interleukin-6 (IL-6) (IL6; OR = 1.97, 95% CI [1.49; 2.62], padj < 0.001) were positively associated with stroke severity measured by mRS, while Lymphocyte antigen 75 (LY75; OR = 0.37, 95% CI [0.19; 0.73], padj = 0.049) and Integrin alpha-11 (ITGA11 OR = 0.24, 95% CI [0.14, 0.40] padj < 0.001) were inversely associated. When investigating the relationships with the NIHSS, IL-6 (β = 0.23, 95% CI [0.12, 0.33] padj = 0.001) and ITGA11 (β = - 0.60, 95% CI [- 0.83, - 0.37] padj < 0.001) were significantly associated. CONCLUSIONS Higher relative concentrations of plasma CLEC4G, CKAP4, and IL-6 were associated with higher stroke severity, whereas LY75 and ITGA11 showed an inverse association. Future research might show a possible use as therapeutic targets and application in individual risk assessments.
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Affiliation(s)
- Lino Braadt
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany.
| | - Markus Naumann
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany
| | - Dennis Freuer
- Epidemiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Timo Schmitz
- Epidemiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Jakob Linseisen
- Epidemiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Michael Ertl
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany
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24
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Wu F, Xiong Y, He SL, Wang XH, Chen XL, Chen WC, Huang QM, Huang XY, Pan ZG, Hu WP, He HF, Zheng F. Fever burden within 24 h after hematoma evacuation predicts early neurological deterioration in patients with intracerebral hemorrhage: a retrospective analysis. Front Neurol 2023; 14:1205031. [PMID: 37538253 PMCID: PMC10395082 DOI: 10.3389/fneur.2023.1205031] [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: 04/13/2023] [Accepted: 07/05/2023] [Indexed: 08/05/2023] Open
Abstract
Background Early neurological deterioration after hematoma evacuation is closely associated with a poor prognosis in patients with intracerebral hemorrhage. However, the relationship between body temperature after hematoma evacuation and early neurological deterioration remains unclear. Therefore, this study aims to explore the possible relationship between body temperature and early neurological deterioration in patients with intracerebral hemorrhage after hematoma evacuation. Methods We retrospectively collected data from patients with cerebral hemorrhage at our institute between January 2017 and April 2022. The Student's t-test, Mann-Whitney U-test, and χ2 Test and Fisher's exact test were used to analyze the clinical baseline data. A univariate logistic regression model was used to evaluate the association between the body temperature indices and early neurological deterioration. The predictive power was assessed using the area under the Receiver Operating Characteristic (ROC) curve. The secondary outcome was a poor functional outcome. Results Among 2,726 patients with intracerebral hemorrhage, 308 who underwent hematoma evacuation were included in the present analysis. A total of 82 patients (22.6%) developed early neurological deterioration. Univariate analysis showed that sex (p = 0.041); body temperature at 6 h (p = 0.005), 12 h (p = 0.01), and 24 h (p = 0.008) after surgery; duration of fever (p = 0.008); and fever burden (p < 0.001) were associated with early neurological deterioration. Multivariate logistic regression showed that fever burden was independently associated with early neurological deterioration (OR = 1.055 per °C × hour, 95%CI 1.008-1.103, p = 0.020). ROC showed that fever burden (AUC = 0.590; 95%CI: 0.514-0.666) could predict the occurrence of early neurological deterioration. Conclusion Fever burden is associated with early neurological deterioration in intracerebral hemorrhage patients undergoing hematoma evacuation. Our findings add to previous evidence on the relationship between the fever burden and the occurrence of early neurological deterioration in patients with intracerebral hemorrhage. Future studies with larger sample sizes are required to confirm these findings.
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Affiliation(s)
- Fan Wu
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yu Xiong
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Shi-ling He
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiao-hua Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xin-li Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Wei-can Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Qiao-mei Huang
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xin-yue Huang
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Zhi-gang Pan
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Wei-peng Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - He-fan He
- Department of Anesthesiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Feng Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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25
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Zhang B, Lei H, Ambler G, Werring DJ, Fang S, Li H, Chen R, Wei J, Chen G, Liu N, Du H. Association between Triglyceride-Glucose Index and Early Neurological Outcomes after Thrombolysis in Patients with Acute Ischemic Stroke. J Clin Med 2023; 12:jcm12103471. [PMID: 37240578 DOI: 10.3390/jcm12103471] [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: 01/05/2023] [Revised: 02/23/2023] [Accepted: 03/09/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND The triglyceride-glucose (TyG) index is a novel biomarker of insulin resistance which might plausibly influence endogenous fibrinolysis and thus early neurological outcomes in patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis using recombinant tissue-plasminogen activator. METHODS We included consecutive AIS patients within 4.5 h of symptom onset undergoing intravenous thrombolysis between January 2015 and June 2022 in this multi-center retrospective observational study. Our primary outcome was early neurological deterioration (END), defined as ≥2 (END2) or ≥ 4 (END4) National Institutes of Health Stroke Scale (NIHSS) score worsening compared to the initial NIHSS score within 24 h of intravenous thrombolysis. Our secondary outcome was early neurological improvement (ENI), defined as a lower NIHSS score at discharge. TyG index was calculated using the log scale of fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2. We evaluated the association of END and ENI with TyG index using a logistic regression model. RESULTS A total of 676 patients with AIS were evaluated. The median age was 68 (Interquartile range, IQR (60-76) years old), and 432 (63.9%) were males. A total of 89 (13.2%) patients developed END2, 61 (9.0%) patients developed END4, and 492 (72.7%) experienced ENI. In multivariable logistic regression analysis, after adjustment for confounding factors, TyG index was significantly associated with increased risks of END2 (categorical variable, vs. lowest tertile, medium tertile odds ratio [OR] 1.05, 95% confidence interval, CI 0.54-2.02, highest tertile OR 2.94, 95%CI 1.64-5.27, overall p < 0.001) and END4 (categorical variable, vs. lowest tertile, medium tertile OR 1.21, 95%CI 0.54-2.74, highest tertile OR 3.80, 95%CI 1.85-7.79, overall p < 0.001), and a lower probability of ENI (categorical variable, vs. lowest tertile, medium tertile OR 1.00, 95%CI 0.63-1.58, highest tertile OR 0.59, 95%CI 0.38-0.93, overall p = 0.022). CONCLUSIONS Increasing TyG index was associated with a higher risk of END and a lower probability of ENI in patients with acute ischemic stroke treated with intravenous thrombolysis.
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Affiliation(s)
- Baixiang Zhang
- Department of Rehabilitation Medicine, Longyan First Affiliated Hospital of Fujian Medical University, Longyan 364099, China
| | - Hanhan Lei
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350005, China
| | - Gareth Ambler
- Department of Statistical Science, University College London, London WC1E 6BT, UK
| | - David J Werring
- Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Shuangfang Fang
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350005, China
| | - Hangfeng Li
- Department of Neurology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan 364099, China
| | - Ronghua Chen
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350005, China
| | - Jin Wei
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Guangliang Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Nan Liu
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350005, China
- Department of Rehabilitation, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Houwei Du
- Stroke Research Center, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China
- Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350005, China
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26
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Tu WJ, Xu Y, Liu Y, Li J, Du J, Zhao J. Intravenous Thrombolysis or Medical Management for Minor Strokes. Thromb Haemost 2023. [PMID: 37037201 DOI: 10.1055/s-0043-1768150] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE To evaluate the outcomes of acute ischemic stroke patients with minor deficits treated with either intravenous thrombolysis (IVT) or routine medical management (MM). METHODS The study included patients with acute ischemic stroke and National Institutes of Health Stroke Scale (NIHSS) scores of 5 or less who were treated with IVT within 4.5 hours from symptom onset and were classified as the IVT group. The MM group consisted of an equal number of patients with minor strokes, matched for sex, age, and severity, who did not receive thrombolysis. Data on patient information were collected for both groups. RESULTS A total of 26,236 patients were included in this study (13,208 in IVT and 13,208 in MM). Of these patients, 67.9% were men, and the mean age was 67.1 years (standard deviation: 10.9). At 3 months, the IVT group had a higher rate of stroke-independent outcome (Rankin Scale score of 0-2) compared with the MM group (IVT vs. MM: 91.6 vs. 88.6%, absolute difference: 2.5%, 95% confidence interval [CI]: 1.6-3.4%, p = 0.008; adjusted hazard ratio [HR]: 1.2, 95% CI: 1.1-1.4, p = 0.003). Furthermore, there was no significant difference in 3-month mortality rates between the IVT and MM groups (IVT vs. MM: 2.1 vs. 2.5%, absolute difference: -0.6%, 95% CI: -1.1 to 0.3%, p = 0.11; adjusted HR: 0.9, 95% CI: 0.8-1.2, p = 0.09). CONCLUSION Compared with MM, IVT does not reduce mortality in minor ischemic stroke but improves functional outcomes in minor stroke with an NIHSS score of 3 to 5.
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Affiliation(s)
- Wen-Jun Tu
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300192, People's Republic of China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yicheng Xu
- Department of Neurology, Aerospace Center Hospital and Peking University Aerospace School of Clinical Medicine, Beijing, People's Republic of China
| | - Yakun Liu
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Jilai Li
- Department of Neurology, Aerospace Center Hospital and Peking University Aerospace School of Clinical Medicine, Beijing, People's Republic of China
| | - Jichen Du
- Department of Neurology, Aerospace Center Hospital and Peking University Aerospace School of Clinical Medicine, Beijing, People's Republic of China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
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27
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Lin CH, Saver JL, Ovbiagele B, Tang SC, Lee M, Liebeskind DS. Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis. J Neurointerv Surg 2023; 15:350-354. [PMID: 35292565 PMCID: PMC10086511 DOI: 10.1136/neurintsurg-2022-018662] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/18/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To conduct a meta-analysis to evaluate the effect of endovascular therapy (EVT) in mild acute ischemic stroke (AIS) due to proximal versus distal occlusions. METHODS We searched PubMed, Embase, the Cochrane Library, and clinicaltrials.gov from January 2000 to September 2021 to identify studies comparing EVT versus best medical management (BMM) in AIS with National Institutes of Health Stroke Scale (NIHSS) scores ≤5 due to proximal internal carotid artery (ICA) or M1 versus distal M2 occlusions. We included studies that reported the number of patients with proximal or distal occlusions separately and reported the number of patients with freedom of disability (modified Rankin Scale (mRS) score 0-1) or functional independence (mRS score 0-2) at 90 days in proximal or M2 occlusions, respectively. OR with 95% CI was used. RESULTS We identified six studies with 653 proximal ICA and M1 occlusion patients and 666 distal M2 occlusion patients. Pooled results showed EVT versus BMM was associated with a higher rate of being disability-free in patients with proximal occlusions (OR 1.58, 95% CI 1.09 to 2.30), but was associated with a lower rate of being disability-free in patients with M2 occlusions (OR 0.70, 95% CI 0.49 to 0.99). Effect of EVT in proximal versus distal occlusions was substantially different (P for interaction=0.002). A similar pattern was seen for functional independence (P for interaction=0.05). CONCLUSIONS For patients with mild AIS, observational data suggest that EVT may be beneficial for proximal ICA or M1 but not for distal M2 occlusions. Randomized trials are needed to confirm these findings. PROSPERO REGISTRATION NUMBER CRD42021281034.
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Affiliation(s)
- Chun-Hsien Lin
- Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Jeffrey L Saver
- Neurology, UCLA, Los Angeles, California, USA.,Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
| | - Bruce Ovbiagele
- University of California San Francisco, San Francisco, California, USA
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng Lee
- Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - David S Liebeskind
- Neurology, UCLA, Los Angeles, California, USA.,Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
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Wang P, Chen W, Chen C, Bivard A, Yu G, Parsons MW, Lin L. Association of Perfusion Lesion Variables With Functional Outcome in Patients With Mild Stroke and Large Vessel Occlusion Managed Medically. Neurology 2023; 100:e627-e638. [PMID: 36307224 PMCID: PMC9946183 DOI: 10.1212/wnl.0000000000201498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 09/15/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The best management of patients with mild stroke and large vessel occlusion (LVO) remains unclear. This study aimed to identify perfusion imaging predictors of poor functional outcome in such patients. METHODS This cohort study retrospectively selected patients enrolled in the International Stroke Perfusion Imaging Registry between August 2011 and April 2022. The registry enrolled patients with acute ischemic stroke and with baseline CT perfusion scanned within 24 hours of stroke onset. This study identified patients with mild symptoms, defined by an NIH Stroke Scale score of ≤5. Patients with LVO of anterior circulation were selected. This study further selected patients who received medical management and excluded patients who received endovascular treatment. The primary outcome was poor functional outcome defined as a modified Rankin Scale of 3-6 at 3 months. Perfusion lesion was defined by delay time > 3 seconds on CTP. Regression analyses were used to identify clinical and imaging variables that predicted poor functional outcome. RESULTS A total of 139 patients with mild stroke were included, of whom 27 (19%) had poor functional outcome. Patients with poor outcome, compared with those with good outcome, had much larger perfusion lesion volume (median 80 mL vs 41 mL, p < 0.001). Perfusion lesion was a significant predictor of poor outcome in either univariable regression (crude OR = 1.02, 95% CI = [1.01-1.03]) or multivariable regression model (adjusted OR = 1.01, 95% CI = [1.01-1.02]), adjusting for occlusion site, good collaterals, baseline stroke severity, age, IV thrombolysis (IVT), and onset to scan time. A perfusion lesion of 65 mL was the optimal cutpoint to identify poor functional outcome (sensitivity = 59%, specificity = 77%). Patients with perfusion lesion ≥65 mL, compared with patients with perfusion lesion <65 mL, showed a much higher rate of poor functional outcome (38% vs 11%, p < 0.001). Of the 139 patients in this study, 95 received IVT. Patients treated with or without IVT did not influence their outcomes (crude OR = 0.74, 95% CI = [0.31-1.78]). DISCUSSION A perfusion lesion of ≥65 mL predicted poor functional outcome in mild stroke patients with LVO.
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Affiliation(s)
| | | | | | | | | | | | - Longting Lin
- From the Department of Neurology (P.W., G.Y.), Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College); Zhangzhou Affiliated Hospital of Fujian Medical University (W.C.), China; Faculty of Health (C.C., M.W.P., L.L.), University of Newcastle; Melbourne Brain Centre (A.B.), University of Melbourne; and South Western Sydney Clinical School (M.W.P., L.L.), University of New South Wales, Australia.
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Lee HJ, Kim T, Koo J, Kim YD, Na S, Choi YH, Song IU, Chung SW. Multiple chronic lacunes predicting early neurological deterioration and long-term functional outcomes according to TOAST classification in acute ischemic stroke. Neurol Sci 2023; 44:611-619. [PMID: 36255539 DOI: 10.1007/s10072-022-06446-5] [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: 09/06/2022] [Accepted: 10/06/2022] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Studies regarding multiple chronic lacunes (MCLs) and clinical outcome according to stroke etiology are scarce. We sought to evaluate the association between MCL and short-term/long-term clinical outcomes according to stroke etiology. PATIENTS AND METHODS We analyzed a prospectively collected stroke registry of acute ischemic stroke patients over 4 years. The enrolled patients were classified as having large artery atherosclerosis (LAA), small vessel occlusion (SVO), cardioembolic (CE) stroke, and other etiology. The early neurological deterioration (END) and favorable outcome at 3 months were assessed. RESULTS A total of 1070 patients were enrolled. Patients with MCL had significantly more END compared to those without MCL both in total population (adjusted odds ratio (OR), 1.7; 95% confidence interval [CI], 1.1-2.5; p = 0.013*) and in the LAA group (adjusted OR, 2.3; 95% CI, 1.3-4.2, p < 0.006). Patients with MCL had a significantly lower OR for favorable outcome at 3 months compared to those without MCL both in total population (adjusted OR, 0.7; 95% CI, 0.5-1.0, p = 0.035) and in the LAA group (adjusted OR, 0.6; 95% CI, 0.3-1.0, p = 0.043). However, MCL was not associated with END or long-term functional outcome in patients with SVO, CE, or other etiology. CONCLUSIONS The presence of MCL was an independent predictive factor for END as well as long-term poor functional outcome in acute ischemic stroke patients. These associations were only observed in patients with LAA, not in those with SVO, CE, or other etiology.
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Affiliation(s)
- Hyuk-Je Lee
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Seoul, Korea
| | - Taewon Kim
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Seoul, Korea.
| | - Jaseong Koo
- Department of Neurology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Young-Do Kim
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Seoul, Korea
| | - Seunghee Na
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Seoul, Korea
| | - Yun Ho Choi
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Seoul, Korea
| | - In-Uk Song
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Seoul, Korea
| | - Sung-Woo Chung
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-ro, Bupyeong-gu, Incheon, 21431, Seoul, Korea
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Dai Z, Cao H, Wang F, Li L, Guo H, Zhang X, Jiang H, Zhu J, Jiang Y, Liu D, Xu G. Impacts of stress hyperglycemia ratio on early neurological deterioration and functional outcome after endovascular treatment in patients with acute ischemic stroke. Front Endocrinol (Lausanne) 2023; 14:1094353. [PMID: 36777360 PMCID: PMC9910688 DOI: 10.3389/fendo.2023.1094353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/13/2023] [Indexed: 01/27/2023] Open
Abstract
Background and Purpose Hyperglycemia has been associated with unfavorable outcome of acute ischemic stroke, but this association has not been verified in patients with endovascular thrombectomy treatment. This study aimed to assess the impact of stress hyperglycemia ratio on early neurological deterioration and favorable outcome after thrombectomy in patients with acute ischemic stroke. Methods Stroke patients with endovascular thrombectomy in two comprehensive centers were enrolled. Early neurological deterioration was defined as ≥4 points increase of National Institutes of Health Stroke Scale (NIHSS) at 24 hours after endovascular procedure. Favorable outcome was defined as modified Rankin Scale (mRS) score of 0-2 at 90 days of stroke onset. Multivariate regression analysis was used to identify the predictors for early neurological deterioration and favorable outcome. Results Among the 559 enrolled, 74 (13.2%) patients developed early neurological deterioration. The predictors for early neurological deterioration were high stress hyperglycemia ratio at baseline (OR =5.77; 95% CI, 1.878-17.742; P =0.002), symptomatic intracranial hemorrhage (OR =4.90; 95% CI, 2.439-9.835; P <0.001) and high NIHSS score after 24 hours (OR =1.11; 95% CI, 1.071-1.151; P <0.001). The predictors for favorable outcome were stress hyperglycemia ratio (OR =0.196, 95% CI, 0.077-0.502; P =0.001), age (OR =0.942, 95% CI, 0.909-0.977; P =0.001), NIHSS score 24 hours after onset (OR =0.757, 95% CI =0.693-0.827; P <0.001), groin puncture to recanalization time (OR =0.987, 95% CI, 0.975-0.998; P =0.025), poor collateral status before treatment (ASITN/SIR grade 0-3, OR =62.017, 95% CI, 25.920-148.382; P <0.001), successful recanalization (mTICI 2b or 3, OR =7.415, 95% CI, 1.942-28.313; P =0.001). Conclusion High stress hyperglycemia ratio may be related to early neurological deterioration and decreased likelihood of favourable outcomes after endovascular thrombectomy in patients with acute ischemic stroke.
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Affiliation(s)
- Zheng Dai
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Haiming Cao
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Feng Wang
- Department of Neurology, Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Lei Li
- Department of Neurology, Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Hongquan Guo
- Department of Neurology, Jinling Hospital, First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Xiaohao Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Haichang Jiang
- Department of Neurology, Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Juehua Zhu
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yongjun Jiang
- Department of Neurology, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Dezhi Liu
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Neurology, First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
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Liu H, Liu K, Zhang K, Zong C, Yang H, Li Y, Li S, Wang X, Zhao J, Xia Z, Song B, Xu X, Gao Y. Early neurological deterioration in patients with acute ischemic stroke: a prospective multicenter cohort study. Ther Adv Neurol Disord 2023; 16:17562864221147743. [PMID: 36710721 PMCID: PMC9880581 DOI: 10.1177/17562864221147743] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/08/2022] [Indexed: 01/26/2023] Open
Abstract
Background There is still no precise knowledge of the causes of progression in patients with acute ischemic stroke (AIS), and we are unable to predict patients at risk. Objective To explore the frequency, predictive factors, and the prognosis of early neurological deterioration (END) in patients with AIS. Methods In this prospective multicenter observational study, we assessed patients with AIS admitted to 18 hospitals in Henan, China. We defined END as an increase of ⩾2 points in total National Institutes of Health Stroke Scale (NIHSS) score or ⩾1 point in the motor items of the NIHSS within 7 days after admission. Risk factors were analyzed using multivariate logistic regression models. Prognosis was evaluated using the modified Rankin Scale (mRS), with poor prognosis defined as mRS 3-6. Results A total of 9114 patients with AIS within 24 h of symptom onset were enrolled in the study. END occurred in 1286 (14.1%) patients. The highest incidence (62.5%) of END occurred within 24 h after admission. After adjusting potential confounders, age, body mass index, waist-hip ratio, systolic blood pressure, baseline NIHSS, disabled at baseline, history of atrial fibrillation, diabetes mellitus, intracranial arterial stenosis, infarct location in the lenticulostriate artery area and cerebral watershed, neutrophils, lymphocytes, uric acid, and triglycerides were identified as independent predictors for END. END was significantly associated with poor prognosis at 90 days, and the adjusted OR was 1.74 (95% CI: 1.53-1.97). Conclusion One in seven hospitalized patients with AIS may experience END within 24 h of onset. The highest incidence of END occurred within 24 h of admission and decreased steeply with time. Easily identifiable risk factors predict END and could help understand the causal mechanisms and thereby prevent END.
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Affiliation(s)
- Hongbing Liu
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Liu
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Zhang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Ce Zong
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongxun Yang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Yapeng Li
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Shen Li
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Wang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiawei Zhao
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
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Han L, Hou Z, Ma M, Ding D, Wang D, Fang Q. Impact of glycosylated hemoglobin on early neurological deterioration in acute mild ischemic stroke patients treated with intravenous thrombolysis. Front Aging Neurosci 2023; 14:1073267. [PMID: 36711206 PMCID: PMC9877605 DOI: 10.3389/fnagi.2022.1073267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Objective In patients with acute mild ischemic stroke treated with intravenous thrombolysis, the relationship between chronic hyperglycemic status and their early neurological deterioration (END) and clinical outcomes is unclear. We attempted to analyze the relationship between glycated hemoglobin (HbA1c) levels and END and 90-day functional outcomes. Participants and methods The research comprised 267 patients with acute mild ischemic stroke. The incidence of END and functional outcomes at 90 days were evaluated between subgroups. END was defined in this study as a rise of at least 1 point in the National Institutes of Health Stroke Scale (NIHSS) score within 72 h of admission, with an excellent outcome of a modified Rankin Scale (mRS) score of 0-1 at 90 days following stroke beginning. The association between HbA1c and END, and clinical outcomes in patients with mild stroke, was assessed by logistic regression after adjusting for confounding factors. In addition, we used receiver operating characteristic (ROC) curves to predict the predictive value of HbA1c for the incidence of END. Results There were 38 patients who suffered END and 105 patients who had disabled functional outcomes at 90 days. In multivariate analysis, elevated HbA1c levels were associated with END (adjusted OR = 1.476; 95% CI: 1.129-1.928; p = 0.004). With HbA1c greater than 7.75%, the ROC curve predicted a higher risk of END. However, they were not associated with patients' functional outcomes at 90 days. Conclusion HbA1c levels were an independent predictor of END in patients with mild stroke, while there was no effect on functional outcomes at 90 days. The impact of HbA1c on functional prognosis may be a contributing factor rather than a direct factor.
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Bai X, Qiu J, Wang Y. Endovascular thrombectomy with or without intravenous alteplase in acute stroke: a systematic review and meta-analysis of randomized clinical trials. J Neurol 2023; 270:223-232. [PMID: 36197568 DOI: 10.1007/s00415-022-11413-3] [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: 07/23/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE This study investigated clinical outcomes after direct endovascular thrombectomy (EVT) compared to bridging therapy (EVT with prior intravenous alteplase) in acute stroke within 4.5 h after onset. METHODS PubMed and Embase were searched for eligible randomized controlled trials. The primary outcome was the rates of neurological functional independence defined as modified Rankin scale score 0-2 at 90 days, whose non-inferiority margin was set at - 15%, - 10%, - 6.5%, - 5%, and - 1.3% for its risk difference (RD). RESULTS We included six studies enrolling 2334 participants. The crude cumulative rates of functional independence were 49.0% with direct EVT vs 50.9% with bridging therapy, without significant difference (Odd ratio [OR] = 0.93, 95% confidence interval [CI] 0.79-1.09) between two groups, where the pooled RD was - 2% (95% CI - 6 to 2%) whose lower 95% CI bound fell within non-inferiority margins of - 15%, - 10%, -6.5%, but not - 5% and - 1.3%. Between the two groups, no significant difference was found in excellent function rate (30.2% vs 30.6%, OR = 0.99, 95% CI 0.82-1.18) with RD of 0% (95% CI - 3 to 4%), mortality rate (16.0% vs 15.0%, OR = 1.08, 95% CI 0.86-1.35) with RD of 1% (95% CI - 2 to 4%), and symptomatic intracranial hemorrhage rate (4.3% vs 5.0%, OR = 0.86, 95% CI 0.58-1.27) with RD of 0% (95% CI - 2 to 1%). CONCLUSIONS No statistical difference was found in functional and safety outcomes between direct EVT and bridging therapy groups in acute stroke within 4.5 h after symptom onset. EVT alone was non-inferior to bridging therapy for several, but not the more stringent, non-inferiority margins.
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Affiliation(s)
- Xuan Bai
- Department of Neurology, People's Hospital of Liaoning Province, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Jianting Qiu
- Department of Neurology, People's Hospital of Liaoning Province, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Yujie Wang
- Department of Neurology, People's Hospital of Liaoning Province, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China.
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Liang H, Yin X, Chen T, Zhang Y, Zhang Q, Lin J, Yin H, Tang J, He Y, Xia P, Zhu Y, Li H, Mo Y, Li Y, Wang Y, Yang X, Hu Z. Excessive Sedentary Time Is Associated with Cognitive Decline in Older Patients with Minor Ischemic Stroke. J Alzheimers Dis 2023; 96:173-181. [PMID: 37742637 DOI: 10.3233/jad-230008] [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] [Indexed: 09/26/2023]
Abstract
BACKGROUND Cognitive impairment is commonly seen after acute ischemic stroke (AIS). Sedentary behaviors increase the risk of dementia among community dwelling population. OBJECTIVE This study aims to investigate the association of sedentary behaviors with poststroke cognitive impairment among older adults with minor AIS. METHODS This cohort study recruited 594 older subjects with minor AIS from three hospitals in China during February 1, 2016, and December 31, 2018. Participants were followed up for two years and the sedentary time per day was self-reported at the end of follow-up. Cognitive functions were assessed by Mini-Mental State Examination (MMSE). Participants were categorized into the high and low sedentary time group according to the median sedentary time of the participants. RESULTS At two years of follow-up, the long sedentary time group had significantly lower MMSE scores than the short sedentary time group [median, (IQR): 21 (18 to 25) versus 22 (18 to 25), p = 0.368]. The long sedentary time group had a higher speed of cognitive decline than the short sedentary time group. Excessive sedentary time was associated with a higher risk of longitudinal cognitive decline (OR: 2.267, 95% CI: 1.594 to 3.225), adjusting for age, sex, education, body mass index, APOE genotype, comorbidities, symptoms of depression, anxiety, and insomnia, baseline MMSE scores and National Institute of Health Stroke Scale scores, cognitive therapy, and TOAST ischemic stroke subtypes. CONCLUSIONS This study identified a possible link between sedentary behaviors and longitudinal cognitive decline among older patients with minor AIS, suggesting that reducing sedentary time might be helpful for preventing poststroke dementia.
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Affiliation(s)
- Hongtao Liang
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | | | - Tian Chen
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yan Zhang
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Qin Zhang
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Jie Lin
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Huan Yin
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Jinghua Tang
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yingyi He
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Ping Xia
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yongping Zhu
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Haihua Li
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yongbiao Mo
- Department of Emergency, People's Hospital of Chongqing Hechuan, Chongqing, China
| | - Yongyong Li
- Department of Gerontology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Wang
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Yang
- Neuroscience Center, General Hospital of Ningxia Medical University, Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia, Yinchuan, China
| | - Zicheng Hu
- Department of Neurology, People's Hospital of Chongqing Hechuan, Chongqing, China
- Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Li S, Ni J, Fan X, Yao M, Feng F, Li D, Qu J, Zhu Y, Zhou L, Peng B. Study protocol of Branch Atheromatous Disease-related stroke (BAD-study): a multicenter prospective cohort study. BMC Neurol 2022; 22:458. [PMID: 36494618 PMCID: PMC9733351 DOI: 10.1186/s12883-022-02976-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 11/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND As a meaningful subtype of ischemic stroke in Asians, Branch atheromatous disease (BAD)-related stroke is associated with high early neurological deterioration (END) and disability, but is understudied and without recommended therapy. The mechanism of END still remains unclear. Branch atheromatous disease-related stroke study (BAD-study) therefore aims to investigate demographic, clinical and radiological features, and prognosis of BAD-related stroke in Chinese patients. METHODS/DESIGN BAD-study is a nationwide, multicenter, consecutive, prospective, observational cohort study enrolling patients aged 18-80 years with BAD-related stroke within 72 h after symptom onset. Initial clinical data, laboratory tests, and imaging data are collected via structured case report form, and follow-ups will be performed at 7 days, 30 days, 90 days, 6 months and 12 months after enrollment. The primary outcome is the score on modified Rankin Scale at 90-day follow-up with single-blinded assessment. Secondary outcomes include END within 7 days, and National institute of health stroke scale score, Barthel index, cerebrovascular events, major bleeding complications, and all-cause mortality during 90-day follow-up. Characteristics of penetrating and parent artery will be assessed by high-resolution magnetic resonance imaging combined with other imaging techniques. DISCUSSION BAD-study can provide demographic, clinical, radiological, and prognostic characteristics of BAD-related stroke, and thereby potentially figure out the vascular mechanism of early neurological deterioration and optimize therapy strategy with the aid of advanced imaging technique. Baseline data and evidence will also be generated for randomized controlled trials on BAD-related stroke in the future.
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Affiliation(s)
- Shengde Li
- grid.506261.60000 0001 0706 7839Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China ,grid.413106.10000 0000 9889 6335State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jun Ni
- grid.506261.60000 0001 0706 7839Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China ,grid.413106.10000 0000 9889 6335State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaoyuan Fan
- grid.413106.10000 0000 9889 6335Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Yao
- grid.506261.60000 0001 0706 7839Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China ,grid.413106.10000 0000 9889 6335State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Feng Feng
- grid.413106.10000 0000 9889 6335Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Dongxue Li
- grid.413106.10000 0000 9889 6335Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianxun Qu
- Research Scientist, Siemens Healthineers, Beijing, China
| | - Yicheng Zhu
- grid.506261.60000 0001 0706 7839Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China ,grid.413106.10000 0000 9889 6335State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lixin Zhou
- grid.506261.60000 0001 0706 7839Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China ,grid.413106.10000 0000 9889 6335State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bin Peng
- grid.506261.60000 0001 0706 7839Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China ,grid.413106.10000 0000 9889 6335State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Widimsky P, Snyder K, Sulzenko J, Hopkins LN, Stetkarova I. Acute ischaemic stroke: recent advances in reperfusion treatment. Eur Heart J 2022; 44:1205-1215. [PMID: 36477996 PMCID: PMC10079392 DOI: 10.1093/eurheartj/ehac684] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
During the last 5–7 years, tremendous progress was achieved in the reperfusion treatment of acute ischaemic stroke during its first few hours from symptom onset. This review summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and (in selected patients) carotid stenting. Novel approaches in prehospital (mobile interventional stroke teams) and early hospital (direct transfer to angiography) management are described, and future perspectives (‘all-in-one’ laboratories with angiography and computed tomography integrated) are discussed. There is reasonable chance for patients with moderate-to-severe acute ischaemic stroke to survive without permanent sequelae when the large-vessel occlusion is removed by means of modern pharmaco-mechanic approach. Catheter thrombectomy is now the golden standard of acute stroke treatment. The role of cardiologists in stroke is expanding from diagnostic help (to reveal the cause of stroke) to acute therapy in those regions where such up-to-date Class I. A treatment is not yet available.
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Affiliation(s)
- Petr Widimsky
- Cardiocenter, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
| | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY , USA
| | - Jakub Sulzenko
- Cardiocenter, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
| | - Leo Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY , USA
| | - Ivana Stetkarova
- Department of Neurology at the Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
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Wang Z, Wang S, Li Y, Wang R, Jiang L, Zheng B, Zhang Y, Wang Q, Wang J. Biomarker of early neurological deterioration in minor stroke and proximal large vessel occlusion: A pilot study. Front Neurol 2022; 13:1019530. [PMID: 36388185 PMCID: PMC9642090 DOI: 10.3389/fneur.2022.1019530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/05/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Plasma neurofilament light chain (pNFL) represents one of the scaffolding proteins of central nervous system axonal injury. The aim of this study was to evaluate pNFL as a predictive biomarker for early neurological deterioration (END) in medically managed patients with large vessel occlusion (LVO) and mild presentation (NIHSS < 6). METHODS This retrospective study was developed from a prospectively collected stroke database, which was conducted at a large academic comprehensive stroke center in western China. Patients who first presented with acute ischemic stroke (AIS) within 24 h of symptom onset were continuously included. Stroke severity was analyzed at admission using the NIHSS score. The pNFL drawn on admission was analyzed with a novel ultrasensitive single-molecule array. RESULTS Thirty-nine consecutive patients were included in the analysis, and 19 (48.72%) patients experienced END. Patients who experienced END had significantly higher pNFL levels (mean, 65.20 vs. 48.28 pg/mL; P < 0.001) and larger infarct volume (mean, 15.46 vs. 9.56 mL; P < 0.001). pNFL was valuable for the prediction of END (OR, 1.170; 95% CI, 1.049-1.306; P = 0.005), even after adjusted for age and sex (OR, 1.178; 95% CI, 1.038-1.323; P = 0.006), blood sampling time, baseline NIHSS, TOAST classification, and infarct volume (OR, 1.168; 95% CI, 1.034-1.320; P = 0.012). The area under the ROC curve was 85.0% (95% CI, 0.731-0.970; P < 0.001). The sensitivity was 73.7%, and the specificity was 80%. CONCLUSION END in minor stroke with LVO was distinguishable from those without END following the determination of pNFL in the blood samples within 24 h of onset. The pNFL is a promising biomarker of END in minor stroke with LVO. CLINICAL TRIAL REGISTRATION ChiCTR1800020330.
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Affiliation(s)
- Zhiqiang Wang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China,Department of Neurology, Chengdu BOE Hospital, Chengdu, China
| | - Shuai Wang
- Department of Outpatient, The General Hospital of Western Theater Command, Chengdu, China
| | - Yuxia Li
- Department of Neurology, Chengdu BOE Hospital, Chengdu, China
| | - Rongyu Wang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lianyan Jiang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bo Zheng
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Yaodan Zhang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qingsong Wang
- Department of Neurology, The General Hospital of Western Theater Command, Chengdu, China
| | - Jian Wang
- Department of Neurology, Ya'an People's Hospital, Ya'an, China,*Correspondence: Jian Wang
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Sarraj A, Albers GW, Blasco J, Arenillas JF, Ribo M, Hassan AE, de la Ossa NP, Wu TYH, Cardona Portela P, Abraham MG, Chen M, Maali L, Kleinig TJ, Cordato D, Wallace AN, Schaafsma JD, Sangha N, Gibson DP, Blackburn SL, De Lera Alfonso M, Pujara D, Shaker F, McCullough-Hicks ME, Moreno Negrete JL, Renu A, Beharry J, Cappelen-Smith C, Rodríguez-Esparragoza L, Olivé-Gadea M, Requena M, Almaghrabi T, Mendes Pereira V, Sitton C, Martin-Schild S, Song S, Ma H, Churilov L, Mitchell PJ, Parsons MW, Furlan A, Grotta JC, Donnan GA, Davis SM, Campbell BCV. Thrombectomy versus Medical Management in Mild Strokes due to Large Vessel Occlusion: Exploratory Analysis from the EXTEND-IA Trials and a Pooled International Cohort. Ann Neurol 2022; 92:364-378. [PMID: 35599458 DOI: 10.1002/ana.26418] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate functional and safety outcomes for endovascular thrombectomy (EVT) versus medical management (MM) in patients with large vessel occlusion (LVO) and mild neurological deficits, stratified by perfusion imaging mismatch. METHODS The pooled cohort consisted of patients with National Institutes of Health Stroke Scale (NIHSS) < 6 and internal carotid artery (ICA), M1, or M2 occlusions from the Extending the Time for Thrombolysis in Emergecy Neurological Deficits - Intra-Arterial (EXTEND-IA) Trial, Tenecteplase vs Alteplase before Endovascular Thrombectomy in Ischemic Stroke (EXTEND-IA TNK) trials Part I/II and prospective data from 15 EVT centers from October 2010 to April 2020. RAPID software estimated ischemic core and mismatch. Patients receiving primary EVT (EVTpri ) were compared to those who received primary MM (MMpri ), including those who deteriorated and received rescue EVT, in overall and propensity score (PS)-matched cohorts. Patients were stratified by target mismatch (mismatch ratio ≥ 1.8 and mismatch volume ≥ 15ml). Primary outcome was functional independence (90-day modified Rankin Scale = 0-2). Secondary outcomes included safety (symptomatic intracerebral hemorrhage [sICH], neurological worsening, and mortality). RESULTS Of 540 patients, 286 (53%) received EVTpri and demonstrated larger critically hypoperfused tissue (Tmax > 6 seconds) volumes (median [IQR]: 64 [26-96] ml vs MMpri : 40 [14-76] ml, p < 0.001) and higher presentation NIHSS (median [IQR]: 4 [2-5] vs MMpri : 3 [2-4], p < 0.001). Functional independence was similar (EVTpri : 77.4% vs MMpri : 75.6%, adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] = 0.82-2.03, p = 0.27). EVT had worse safety regarding sICH (EVTpri : 16.3% vs MMpri : 1.3%, p < 0.001) and neurological worsening (EVTpri : 19.6% vs MMpri : 6.7%, p < 0.001). In 414 subjects (76.7%) with target mismatch, EVT was associated with improved functional independence (EVTpri : 77.4% vs MMpri : 72.7%, aOR = 1.68, 95% CI = 1.01-2.81, p = 0.048), whereas there was a trend toward less favorable outcomes with primary EVT (EVTpri : 77.4% vs MMpri : 83.3%, aOR = 0.39, 95% CI = 0.12-1.34, p = 0.13) without target mismatch (pinteraction = 0.06). Similar findings were observed in a propensity score-matched subpopulation. INTERPRETATION Overall, EVT was not associated with improved clinical outcomes in mild strokes due to LVO, and sICH was increased. However, in patients with target mismatch profile, EVT was associated with increased functional independence. Perfusion imaging may be helpful to select mild stroke patients for EVT. ANN NEUROL 2022;92:364-378.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | | | - Jordi Blasco
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Juan F Arenillas
- Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX, USA
| | | | - Teddy Yuan-Hao Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Laith Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis Cordato
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Joanna D Schaafsma
- Neurology, Department of Internal Medicine, Toronto Western Hospital-University Health Network, Toronto, ON, Canada
| | - Navdeep Sangha
- Department of Neurology, Kaiser Permanente, Los Angeles, CA, USA
| | - Daniel P Gibson
- Department of Neurosurgery, Ascension Wisconsin, Milwaukee, WI, USA
| | - Spiros L Blackburn
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, TX, USA
| | | | - Deep Pujara
- Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | - Faris Shaker
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, TX, USA
| | | | | | - Arturo Renu
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - James Beharry
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Cecilia Cappelen-Smith
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Tareq Almaghrabi
- Department of Internal Medicine, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
| | | | - Clark Sitton
- Department of Diagnostic and Interventional Radiology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Sheryl Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, LA, USA
| | - Sarah Song
- Department of Neurology, Rush University Medical Center, Chicago, IL, USA
| | - Henry Ma
- Department of Neurology, Monash University, Melbourne, Vic., Australia
| | - Leonid Churilov
- Department of Biostatistics, University of Melbourne, Parkville, Vic., Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, Parkville, Vic., Australia
| | - Mark W Parsons
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool Hospital, Liverpool, NSW, Australia
| | - Anthony Furlan
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Stroke Division, University Hospitals Neurological institute, Cleveland, OH, USA
| | - James C Grotta
- Department of Clinical Innovation and Research, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
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Regenhardt RW, Awad A, Kraft AW, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Etherton MR, Hirsch JA, Rabinov JD, Singhal AB, Rost NS, Stapleton CJ, Leslie-Mazwi TM, Patel AB. Characterizing reasons for stroke thrombectomy ineligibility among potential candidates transferred in a hub-and-spoke network. STROKE (HOBOKEN, N.J.) 2022; 2:e000282. [PMID: 36187724 PMCID: PMC9524427 DOI: 10.1161/svin.121.000282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background Access to endovascular thrombectomy (EVT) is relatively limited. Hub-and-spoke networks seek to transfer appropriate large vessel occlusion (LVO) candidates to EVT-capable hubs. However, some patients are ineligible upon hub arrival, and factors that drive transfer inefficiencies are not well described. We sought to quantify EVT transfer efficiency and identify reasons for EVT ineligibility. Methods Consecutive EVT candidates presenting to 25 spokes from 2018-2020 with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day modified Rankin Scale (mRS) ≤2. Results Among 258 patients, the median age was 70 years (IQR 60-81); 50% were female. 56% were ineligible for EVT after hub arrival. Cited reasons were large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion (5%), sub-occlusive lesion (3%), and goals of care (3%). Late window patients [last known well (LKW) >6 hours] were more likely to be ineligible (67% vs 43%, P<0.0001). EVT ineligible patients were older (73 vs 68 years, p=0.04), had lower NIHSS (10 vs 16, p<0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p<0.0001), longer spoke Telestroke consult-hub arrival time (2.8 vs 2.2 hours, p<0.0001), and received less intravenous thrombolysis (32% vs 45%, p=0.04) compared to eligible patients. EVT ineligibility independently reduced the odds of 90-day mRS≤2 (aOR=0.26, 95%CI=0.12,0.56; p=0.001) when controlling for age, NIHSS, and LKW-hub arrival time. Conclusions Among patients transferred for EVT, there are multiple reasons for ineligibility upon hub arrival, with most excluded for infarct growth and mild symptoms. Understanding factors that drive transfer inefficiencies is important to improve EVT access and outcomes.
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Affiliation(s)
- Robert W Regenhardt
- Neurosurgery, Massachusetts General Hospital
- Neurology, Massachusetts General Hospital
| | - Amine Awad
- Neurology, Massachusetts General Hospital
| | | | | | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
| | | | | | | | | | - James D Rabinov
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
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40
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Li XQ, Cui Y, Wang XH, Chen HS. Early Antiplatelet for Minor Stroke following Thrombolysis (EAST): Rationale and Design. Int J Stroke 2022; 18:615-619. [PMID: 35899772 DOI: 10.1177/17474930221118900] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Early neurological deterioration (END) occurs in about 10% of patients after intravenous thrombolysis (IVT), and is related to poor outcome. In theory, early antiplatelet following IVT could reduce END by preventing re-occlusion and stroke progression, but current guidelines recommend starting antiplatelet treatment at 24 hours after IVT due to concerns about hemorrhagic transformation. Given higher risk of hemorrhagic transformation in severe stroke, we hypothesized that minor stroke patients following IVT can safely benefit from early antiplatelet treatment. AIMS To explore the efficacy and safety of early antiplatelet in minor stroke patients after IVT.Sample size estimates: A maximum of 1022 patients are required to test the superiority hypothesis with 80% power according to a two-side 0.05 level of significance, stratified by age, gender, history of stroke or transient ischemic attack, history of hypertension, history of diabetes mellitus, systolic blood pressure at admission, time from IVT to treatment, thrombolysis drug, stroke territory, and stroke etiology. DESIGN Early antiplatelet for minor stroke following thrombolysis is a prospective, double blinded, multicenter, randomized and placebo-controlled trial. Minor stroke patients within 6h following IVT are randomly assigned into experimental group and control group with the ratio of 1:1. The experimental group is orally administered with 300 mg clopidogrel and 100 mg aspirin, and control group with placebo. Subsequently, both groups received guideline-based antithrombotic treatment from 24 hours after IVT to 90 days. OUTCOME The primary efficacy endpoint is excellent functional outcome, defined as the modified Rankin Scale 0-1 at 90 days after randomization, while primary safety endpoint is symptomatic intracerebral hemorrhage, defined as National Institutes of Health Stroke Scale score increase ≥4 caused by intracranial hemorrhage within 36 hours after randomization. CONCLUSIONS The results of EAST will provide us powerful early antiplatelet evidence for minor stroke population following intravenous thrombolysis in clinical practice.
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Affiliation(s)
- Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China 74643
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China 74643
| | - Xin-Hong Wang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China 74643
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China 74643
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41
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Feil K, Matusevicius M, Herzberg M, Tiedt S, Küpper C, Wischmann J, Schönecker S, Mengel A, Sartor‐Pfeiffer J, Berger K, Dimitriadis K, Liebig T, Dieterich M, Mazya M, Ahmed N, Kellert L. Minor stroke in large vessel occlusion: A matched analysis of patients from the German Stroke Registry-Endovascular Treatment (GSR-ET) and patients from the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Eur J Neurol 2022; 29:1619-1629. [PMID: 35122371 PMCID: PMC9306813 DOI: 10.1111/ene.15272] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Reperfusion treatment in patients presenting with large vessel occlusion (LVO) and minor neurological deficits is still a matter of debate. We aimed to compare minor stroke patients treated with endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or IVT alone. METHODS Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) and the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) between June 2015 and December 2019 were analyzed. Minor stroke was defined as National Institutes of Health Stroke Scale (NIHSS) score ≤5, and LVO as occlusion of the internal carotid, carotid-T, middle cerebral, basilar, vertebral or posterior cerebral arteries. GSR-ET and SITS-ISTR IVT-treated patients were matched in a 1:1 ratio using propensity-score (PS) matching. The primary outcome was good functional outcome at 3 months (modified Rankin Scale score 0-2). RESULTS A total of 272 GSR-ET patients treated with EVT and IVT (age 68.6 ± 14.0 years, 43.4% female, NIHSS score 4 [interquartile range 2-5]) were compared to 272 IVT-treated SITS-ISTR patients (age 69.4 ± 13.7, 43.4% female, NIHSS score 4 [2-5]). Good functional outcome was seen in 77.0% versus 82.9% (p = 0.119), mortality in 5.9% versus 7.9% (p = 0.413), and intracranial hemorrhage in 8.8% versus 12.5% (p = 0.308) of patients in the GSR-ET versus the SITS-ISTR IVT group, respectively. In a second PS-matched analysis, 624 GSR-ET patients (IVT rate 56.7%) and 624 SITS-ISTR patients (IVT rate 100%), good outcome was more often observed in the SITS-ISTR patients (68.2% vs. 80.9%; p < 0.001), and IVT independently predicted good outcome (odds ratio 2.16, 95% confidence interval 1.43-3.28). CONCLUSIONS Our study suggests similar effectiveness of IVT alone compared to EVT with or without IVT in minor stroke patients. There is an urgent need for randomized controlled trials on this topic.
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Affiliation(s)
- Katharina Feil
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Marius Matusevicius
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of Research and EducationKarolinska University HospitalStockholmSweden
| | - Moriz Herzberg
- Institute of NeuroradiologyLMUMunichGermany,Department of RadiologyUniversity HospitalWuerzburgGermany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | - Clemens Küpper
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Johannes Wischmann
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Sonja Schönecker
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Annerose Mengel
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Jennifer Sartor‐Pfeiffer
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Katharina Berger
- Department of Neurology and EpileptologyEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Konstantin Dimitriadis
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | | | - Marianne Dieterich
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Munich Cluster for Systems Neurology (SyNergy)MunichGermany,German Center for Vertigo and Balance DisordersLMUMunichGermany
| | - Michael Mazya
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Niaz Ahmed
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Lars Kellert
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
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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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Pellegrino MP, Guerra FBD, Perissinotti IN. Decision-making strategies for reperfusion therapies: navigating through stroke trials gaps. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:60-71. [PMID: 35976313 PMCID: PMC9491414 DOI: 10.1590/0004-282x-anp-2022-s123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Despite there being a robust amount of literature and numerous randomized clinical trials regarding acute ischemic stroke treatment, the trials have not included some frequent controversial situations for which decision-making strategies are an urgent and unmet need in clinical practice. This article tries to summarize the current evidence about some selected situations (mechanical thrombectomy in low ASPECTS, low NIHSS with proximal occlusion, acute basilar occlusion, distal and medium vessel occlusion, among others), make suggestions on how to approach them in clinical practice and show what to expect in acute stroke research in the near future.
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Affiliation(s)
- Mateus Paquesse Pellegrino
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo, SP, Brazil
| | | | - Iago Navas Perissinotti
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto Central, Departamento de Neurologia, São Paulo, SP, Brazil
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Rescue Revascularisation in Acute Internal Carotid Artery Occlusion with a Super Extended Time Window of More than 48 hours. Case Rep Neurol Med 2022; 2022:9036082. [PMID: 35535177 PMCID: PMC9078832 DOI: 10.1155/2022/9036082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
Methods We present the case of a 71-year-old Caucasian male “minor stroke” patient with LVO, good collateral flow via the ophthalmic artery, receiving rescue MT following clinical deterioration after >48 hours. NIHSS and modified Rankin scale (mRS) were used for follow-up and modified treatment in cerebral infarction (mTICI) score for angiographic results. Results Excellent angiographic result (mTICI 3) and clinical improvement were achieved (NIHSS preintervention 18, on discharge 2 points). 90-day follow-up showed excellent outcome (mRS 1). Conclusions Late intervention MT should be encouraged when clinical deficit exceeds infarct demarcation. Standardized identification based on clinical and imaging data is required to target critical patients with LVO and low NIHSS, favouring a primary intervention.
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Patra DP, Demaerschalk BM, Chong BW, Krishna C, Bendok BR. A Renaissance in Modern and Future Endovascular Stroke Care. Neurosurg Clin N Am 2022; 33:169-183. [DOI: 10.1016/j.nec.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Fiehler J, Nawka MT, Meyer L. Persistent challenges in endovascular treatment decision-making for acute ischaemic stroke. Curr Opin Neurol 2022; 35:18-23. [PMID: 34812746 DOI: 10.1097/wco.0000000000001006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although endovascular treatment (EVT) is the gold standard for treating acute stroke patients with large vessel occlusion (LVO), multiple challenges in decision-making for specific conditions persist. Recent evidence on a selection of patient subgroups will be discussed in this narrative review. RECENT FINDINGS Two randomized controlled trials (RCTs) have been published in EVT of basilar artery occlusion (BAO). Large single arm studies showed promising results in Patients with low Alberta stroke program early CT score (ASPECTS) and more distal vessel occlusions. Recent data confirm patients with low National Institutes of Health Stroke Scale (NIHSS) despite LVO to represent a heterogeneous and challenging patient group. SUMMARY The current evidence does not justify withholding EVT from BAO patients as none of the RCTs showed any signal of superiority of BMT alone vs. EVT. Patients with low ASPECTS, more distal vessel occlusions and patients with low NIHSS scores should be included into RCTs if possible. Without participation in a RCT, patients should be selected for EVT based on age, severity and type of neurological impairment, time since symptom onset, location of the ischaemic lesion and perhaps also results of advanced imaging.
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Affiliation(s)
- Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Gwak DS, Choi W, Kwon JA, Shim DH, Kim YW, Hwang YH. Perfusion profile evaluated by severity-weighted multiple Tmax strata predicts early neurological deterioration in minor stroke with large vessel occlusion. J Cereb Blood Flow Metab 2022; 42:329-337. [PMID: 34559021 PMCID: PMC9122513 DOI: 10.1177/0271678x211029165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minor stroke due to large vessel occlusion (LVO) is associated with poor outcomes. Hypoperfused tissue fate may be more accurately predicted by severity-weighted multiple perfusion strata than by a single perfusion threshold. We investigated whether poor perfusion profile evaluated by multiple Tmax strata is associated with early neurological deterioration (END) in patients with minor stroke with LVO. Ninety-four patients with a baseline National Institute of Health Stroke Scale score ≤5 and anterior circulation LVO admitted within 24 hours of onset were included. Tmax strata proportions (Tmax 2-4 s, 4-6 s, 6-8 s, 8-10 s, and >10 s) against the entire hypoperfusion volume (Tmax >2 s) were measured. The perfusion profile was defined as the shift of the distribution of the Tmax strata proportions towards worse hypoperfusion severity compared with that of the entire cohort using the Wilcoxon-Mann-Whitney generalised odds ratio (OR); its performance to predict END was tested. The area under the curve of perfusion profile was 0.785 (95% confidence interval [CI]: 0.691-0.878, p < 0.001). Poor perfusion profile (generalised OR >1.052) was independently associated with END (adjusted OR 13.42 [95% CI: 4.38-41.15], p < 0.001). Thus, perfusion profile with severity-weighted multiple Tmax strata may predict END in minor stroke and LVO.
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Affiliation(s)
- Dong-Seok Gwak
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - WooChan Choi
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jung-A Kwon
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Dong-Hyun Shim
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Yong-Won Kim
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yang-Ha Hwang
- Department of Neurology, 65396Kyungpook National University Hospital, Kyungpook National University Hospital, Daegu, Republic of Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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Duloquin G, Crespy V, Jakubina P, Giroud M, Vergely C, Béjot Y. Large Vessel Occlusion in Patients With Minor Ischemic Stroke in a Population-Based Study. The Dijon Stroke Registry. Front Neurol 2022; 12:796046. [PMID: 35095739 PMCID: PMC8795366 DOI: 10.3389/fneur.2021.796046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Strategy for the acute management of minor ischemic stroke (IS) with large vessel occlusion (LVO) is under debate, especially the benefits of mechanical thrombectomy. The frequency of minor IS with LVO among overall patients is not well established. This study aimed to assess the proportion of minor IS and to depict characteristics of patients according to the presence of LVO in a comprehensive population-based setting. Methods: Patients with acute IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013–2017). All arterial imaging exams were reviewed to assess arterial occlusion. Minor stroke was defined as that with a National Institutes of Health Stroke Scale (NIHSS) score of <6. Proportion of patients with LVO was estimated in the minor IS population. The clinical presentation of patients was compared according to the presence of an LVO. Results: Nine hundred seventy-one patients were registered, including 582 (59.9%) patients with a minor IS. Of these patients, 23 (4.0%) had a LVO. Patients with minor IS and LVO had more severe presentation [median 3 (IQR 2–5) vs. 2 (IQR 1–3), p = 0.001] with decreased consciousness (13.0 vs. 1.6%, p<0.001) and cortical signs (56.5 vs. 30.8%, p = 0.009), especially aphasia (34.8 vs. 15.4%, p = 0.013) and altered item level of consciousness (LOC) questions (26.1 vs. 11.6%, p = 0.037). In multivariable analyses, only NIHSS score (OR = 1.45 per point; 95% CI: 1.11–1.91, p = 0.007) was associated with proximal LVO in patients with minor IS. Conclusion: Large vessel occlusion (LVO) in minor stroke is non-exceptional, and our findings highlight the need for emergency arterial imaging in any patients suspected of acute stroke, including those with minor symptoms because of the absence of obvious predictors of proximal LVO.
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Volbers B, Gröger R, Engelhorn T, Marsch A, Macha K, Schwab S, Dörfler A, Lang S, Kallmünzer B. Acute Stroke With Large Vessel Occlusion and Minor Clinical Deficits: Prognostic Factors and Therapeutic Implications. Front Neurol 2021; 12:736795. [PMID: 34744977 PMCID: PMC8568768 DOI: 10.3389/fneur.2021.736795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/16/2021] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: The optimal acute management of patients with large vessel occlusion (LVO) and minor clinical deficits on admission [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] remains to be elucidated. The aim of the present study was to investigate the prognostic factors and therapeutic management of those patients. Methods: In this retrospective cohort study, we investigated (1) all patients with acute ischemic stroke due to an LVO who underwent mechanical thrombectomy (MT) and (2) all patients with minor clinical deficits (NIHSS ≤ 4) on admission due to an LVO between January 2013 and December 2016 at the University Medical Center Erlangen. We dichotomized management of patients with minor deficits treated with MT for analysis according to immediate mechanical thrombectomy (IT) and initial medical management with rescue intervention (MM) in case of secondary deterioration. Primary endpoints were secondary deterioration, in-hospital mortality, and functional outcome on day 90 (dichotomized modified Rankin Scale 0–2: favorable, 3–6: poor). Results: Two hundred twenty-three patients (83% with anterior circulation stroke, 13 (6%) with minor deficits) treated with MT and 88 patients with minor deficits due to LVO [13 (15%) treated with MT] were included. Secondary deterioration (n = 19) was independently associated with poor outcome in patients with minor deficits and LVO [odds ratio (OR), 0.060; 95% confidence interval (CI), 0.013–0.280], which in turn was associated with the occlusion site [especially M1 occlusion: 11 (58%) vs. 3 (4%) in patients without secondary deterioration, p < 0.0001]. IT (n = 8) was associated with a lower intrahospital mortality compared to MM (n = 5; 13 vs. 80%; OR, 0.036; 95% CI, 0.002–0.741). Seven of eight patients with IT survived until discharge, with 29% showing a favorable functional outcome on day 90. Conclusions: Secondary deterioration is associated with poor outcome in patients with LVO and minor deficits, which in turn was associated with occlusion site. Future randomized controlled trials should assess whether selected patients, depending on occlusion site and associated characteristics, may benefit from MT.
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Affiliation(s)
- Bastian Volbers
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Rebecca Gröger
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Armin Marsch
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Lang
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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