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Knapen RRMM, Frol S, van Kuijk SMJ, Oblak JP, van der Leij C, van Oostenbrugge RJ, van Zwam WH. Intravenous thrombolysis for ischemic stroke in the posterior circulation: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107641. [PMID: 38395096 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107641] [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: 12/08/2023] [Revised: 02/06/2024] [Accepted: 02/18/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES Intravenous thrombolysis (IVT) is recommended in patients with ischemic stroke in the anterior and posterior circulation. Neurological outcomes due to posterior circulation strokes (PCS) without treatment remain poor. Our aim was to overview the literature on outcomes of IVT and conservative treatment in PCS, based on a systematic review and meta-analysis. METHODS A systematic literature search was performed on February 27th 2023. Outcome measures included favorable functional outcome at 90 days (modified Rankin Scale [mRS] 0-2), mortality at 90 days, and symptomatic intracranial hemorrhages (sICH). Weighted averages with DerSimonian-Laird approach was used to analyze the data. Subgroup analyses by time window were performed: standard time window (<4.5 hours after symptom onset) and extended time window (>4.5 hours). Analyses were performed using R. RESULTS Eight prospective and four retrospective cohort studies were included (n = 1589 patients); no studies with conservative treatment were eligible. The pooled weighted probability regarding favorable functional outcome after IVT was 63 % (95 %CI:0.45-0.78), for mortality 19 % (95 %CI:0.11-0.30), and for sICH 4 % (95 %CI:0.02-0.07). Subgroup analyses showed higher probabilities on achieving favorable functional outcomes for patients treated in the standard (77 %; 95 %CI:0.62-0.88) compared to the extended time window (38 %; 95 %CI:0.29-0.48) with RR = 1.93 (95 %CI:1.66-2.24). Lower probabilities regarding mortality at 90 days and sICH were seen in patients treated in standard compared to extended time window (RR = 0.42, 95 %CI:0.34-0.51 and RR = 0.27, 95 %CI:0.16-0.45, respectively). CONCLUSIONS IVT in patients with PCS seems to be safe and effective in standard and extended time window. The effect of IVT is higher in the standard time window.
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Affiliation(s)
- Robrecht R M M Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ and CARIM, School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands.
| | - Senta Frol
- Departmenta of Vascular Neurology, University Medical Center Ljubljana and Faculty of medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Janja Pretnar Oblak
- Departmenta of Vascular Neurology, University Medical Center Ljubljana and Faculty of medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Christiaan van der Leij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center+ and CARIM, School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ and CARIM, School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
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Liu Z, Zhang S, Wang Y, Xu H, Gao Y, Jin H, Zhang Y, Wu H, Lu J, Chen P, Qiao PG, Yang Z. Posterior circulation ischemic stroke: radiomics-based machine learning approach to identify onset time from magnetic resonance imaging. Neuroradiology 2024:10.1007/s00234-024-03353-8. [PMID: 38592454 DOI: 10.1007/s00234-024-03353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/02/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE Posterior circulation ischemic stroke (PCIS) possesses unique features. However, previous studies have primarily or exclusively relied on anterior circulation stroke cases to build machine learning (ML) models for predicting onset time. To date, there is no research reporting the effectiveness and stability of ML in identifying PCIS onset time. We aimed to build diffusion-weighted imaging-based ML models to identify the onset time of PCIS patients. METHODS Consecutive PCIS patients within 24 h of definite symptom onset were included (112 in the training set and 49 in the independent test set). Images were processed as follows: volume of interest segmentation, image feature extraction, and feature selection. Five ML models, naïve Bayes, logistic regression, tree ensemble, k-nearest neighbor, and random forest, were built based on the training set to estimate the stroke onset time (binary classification: ≤ 4.5 h or > 4.5 h). Relative standard deviations (RSD), receiver operating characteristic (ROC) curves, and the calibration plot was performed to evaluate the stability and performance of the five models. RESULTS The random forest model had the best performance in the test set, with the highest area under the curve (AUC, 0.840; 95% CI: 0.706, 0.974). This model also achieved the highest accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (83.7%, 64.3%, 91.4%, 75.0%, and 86.5%, respectively). Furthermore, the model had high stability (RSD = 0.0094). CONCLUSION The PCIS case-based ML model was effective for estimating the symptom onset time and achieved considerably high specificity and stability.
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Affiliation(s)
- Zhenhao Liu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Shiyu Zhang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Yuxin Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Hui Xu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Yongqiang Gao
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Hong Jin
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Yufeng Zhang
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Hongyang Wu
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Jun Lu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Peipei Chen
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Peng-Gang Qiao
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China.
| | - Zhenghan Yang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China.
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Černík D, Ospalík D, Šaňák D, Cihlář F. Repeated Intravenous Thrombolysis in Patients with Recurrent Ischemic Stroke in the Vertebrobasilar Territory. Case Rep Neurol 2021; 13:510-514. [PMID: 34720955 PMCID: PMC8460951 DOI: 10.1159/000518193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/29/2021] [Indexed: 11/23/2022] Open
Abstract
Acute ischemic vertebrobasilar stroke (AIVBS) is usually associated with poor outcome and prognosis and in case of basilar artery occlusion (BAO) with high mortality. Intravenous thrombolysis (IVT), as a standard recanalization therapy of acute ischemic stroke (IS) within first 4.5 h, can be administrated beyond this therapeutic time window in case of symptomatic BAO. Repeated IVT is generally contraindicated in case of early recurrent IS, despite a risk of poor outcome or death after recurrent IS. The aim was to present 2 cases of repeated IVT for recurrent AIVBS and discuss specific situations where repeated IVT may be considered. Up to now, repeated IVT has been reported only in recurrent stroke in anterior circulation.
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Affiliation(s)
- David Černík
- Department of Neurology, Comprehensive Stroke Center, Masaryk Hospital Ústí nad Labem, KZ a.s., Ústí nad Labem, Czechia
| | - Dušan Ospalík
- Department of Neurology, Comprehensive Stroke Center, Masaryk Hospital Ústí nad Labem, KZ a.s., Ústí nad Labem, Czechia
| | - Daniel Šaňák
- Department of Neurology, Comprehensive Stroke Center, Palacký University Medical, School and Hospital, Olomouc, Czechia
| | - Filip Cihlář
- Department of Radiology, Masaryk Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czechia
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Handelsmann H, Herzog L, Kulcsar Z, Luft AR, Wegener S. Predictors for affected stroke territory and outcome of acute stroke treatments are different for posterior versus anterior circulation stroke. Sci Rep 2021; 11:10544. [PMID: 34006885 PMCID: PMC8131617 DOI: 10.1038/s41598-021-89871-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/26/2021] [Indexed: 01/14/2023] Open
Abstract
Distinct patient characteristics have been proposed for ischaemic stroke in the anterior versus posterior circulation. However, data on functional outcome according to stroke territory in patients with acute stroke treatment are conflicting and information on outcome predictors is scarce. In this retrospective study, we analysed functional outcome in 517 patients with stroke and thrombolysis and/or thrombectomy treated at the University Hospital Zurich. We compared clinical factors and performed multivariate logistic regression analyses investigating the effect of outcome predictors according to stroke territory. Of the 517 patients included, 80 (15.5%) suffered a posterior circulation stroke (PCS). PCS patients were less often female (32.5% vs. 45.5%, p = 0.031), received thrombectomy less often (28.7% vs. 48.3%, p = 0.001), and had lower median admission NIHSS scores (5 vs. 10, p < 0.001) as well as a better median three months functional outcome (mRS 1 vs. 2, p = 0.010). Predictors for functional outcome were admission NIHSS (OR 0.864, 95% CI 0.790–0.944, p = 0.001) in PCS and age (OR 0.952, 95% CI 0.935–0.970, p < 0.001), known symptom onset (OR 1.869, 95% CI 1.111–3.144, p = 0.018) and admission NIHSS (OR 0.840, 95% CI 0.806–0.876, p < 0.001) in ACS. Acutely treated PCS and ACS patients differed in their baseline and treatment characteristics. We identified specific functional outcome predictors of thrombolysis and/or thrombectomy success for each stroke territory.
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Affiliation(s)
- H Handelsmann
- Department of Neurology and Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland
| | - L Herzog
- Department of Neurology and Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.,Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland.,Institute of Data Analysis and Process Design, ZHAW Winterthur, Winterthur, Switzerland
| | - Z Kulcsar
- Department of Neuroradiology and Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - A R Luft
- Department of Neurology and Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.,Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - S Wegener
- Department of Neurology and Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.
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Huang Q, Song HQ, Ma QF, Song XW, Wu J. Effects of time delays on the therapeutic outcomes of intravenous thrombolysis for acute ischemic stroke in the posterior circulation: An observational study. Brain Behav 2019; 9:e01189. [PMID: 30614220 PMCID: PMC6379513 DOI: 10.1002/brb3.1189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 11/16/2018] [Accepted: 11/23/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We aim to demonstrate the effects of time delays on the therapeutic outcomes of intravenous thrombolysis (IVT) in acute posterior circulation stroke (PCS) patients. METHODS Consecutive PCS cases treated with IVT alone were retrospectively examined. The primary end point was set to be a favorable outcome (modified Rankin Scale [mRS] ≤2) at 3 months, and angiographic recanalization was set to be the secondary outcome. RESULTS A total of 95 PCS cases with IVT were recruited. The patients with favorable outcomes and those without favorable outcomes had similar baseline characteristics, except for significantly lower National Institute of Health Stroke Scale (NIHSS) scores (5 vs. 12, respectively; p < 0.001) and less hyperdense basilar artery signs in head CTs (26.5% vs. 70.4%, respectively; p < 0.001) for those with favorable outcomes. For patients with an onset-to-treatment time (OTT) of 0-90 min (n = 5), 91-180 min (n = 38), 181-270 min (n = 37), or ≧271 min (n = 15), the rate of favorable outcome was 100.0%, 71.1%, 67.6%, or 73.3%, respectively, and the Cochran-Armitage trend test showed no linear trend between the OTT and the clinical prognosis of IVT in PCS (p = 0.501) patients. In addition, the rates of recanalization were 100.0%, 68.4%, 64.9%, and 46.7%, and the Cochran-Armitage trend test suggested a linear trend between the OTT and recanalization (p = 0.046); that is, the proportion of PCS patients who underwent recanalization decreased with increasing OTTs. In the multivariate logistic regression analysis, after adjusting for confounding factors with p ≦ 0.20 in the univariate analysis, baseline NIHSS scores and hyperdense basilar artery signs were negatively associated with favorable outcomes, with odds ratios (OR) of 0.884 (95% confidence interval [CI], 0.804-0.971; p = 0.010) and 0.208 (95% CI, 0.062-0.693; p = 0.011), respectively. In addition, there was a negative association between recanalization, OTTs (OR, 0.993, 95% CI, 0.987-0.999; p = 0.029), and baseline NIHSS scores (OR, 0.881, 95% CI, 0.802-0.967; p = 0.008). CONCLUSION Irrespective of stroke severity, the therapeutic effects of recanalization after IVT decreased significantly with longer time delays in PCS patients.
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Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hai-Qing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qing-Feng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Song
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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