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Kanamaru T, Suda S, Muraga K, Ishiwata A, Aoki J, Suzuki K, Sakamoto Y, Katano T, Nishimura T, Nishiyama Y, Kimura K. Pre-stroke cognitive impairment in acute ischemic stroke patients predicts poor functional outcome after mechanical thrombectomy. Neurol Sci 2021; 42:4629-4635. [PMID: 33666769 DOI: 10.1007/s10072-021-05158-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/27/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Several studies have investigated the predictors of functional outcome in patients with ischemic stroke after mechanical thrombectomy (MT). However, it is not clear whether pre-stroke cognitive (PSC) impairment is associated with the functional outcome of patients treated with MT. METHODS We enrolled 113 patients treated with MT from December 2016 to November 2018. PSC was evaluated using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Poor outcome was defined as a modified Rankin Scale score of 3-6. We compared the clinical characteristics between the groups with poor outcome (n = 61) and good outcome (n = 52) to determine if PSC could be a predictor of poor outcome. RESULTS IQCODE was significantly higher in the group with poor outcome than good outcome (3.34 vs. 3.13, P = 0.017). Moreover, the following metrics differed between those two groups: age (75.9 vs. 71.6 years old, P = 0.010), the percentage of females (39.9% vs. 17.3%, P = 0.009), the percentage with hypertension (72.1% vs. 44.2%, P = 0.003), National Institutes of Health Stroke Scale (NIHSS) score on admission (20 vs. 11, P < 0.001), and no successful recanalization (24.5% vs. 7.7%; P = 0.025). Multivariable logistic regression analysis demonstrated that PSC (OR: 5.59; 95% CI: 1.55-23.47), history of hypertension (OR: 3.33; 95% CI: 1.29-9.11), no successful recanalization (OR: 5.51; 95% CI: 1.49-25.03), and NIHSS score on admission (OR: 1.14; 95% CI: 1.07-1.22) were associated with poor outcome 3 months after stroke onset. CONCLUSIONS PSC was significantly and independently associated with poor functional outcome in patients treated with MT.
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Affiliation(s)
- Takuya Kanamaru
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Satoshi Suda
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kanako Muraga
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Akiko Ishiwata
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Junya Aoki
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yuki Sakamoto
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Takehiro Katano
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Takuya Nishimura
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yasuhiro Nishiyama
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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Lauksio I, Lindström I, Khan N, Sillanpää N, Hernesniemi J, Oksala N, Protto S. Brain atrophy predicts mortality after mechanical thrombectomy of proximal anterior circulation occlusion. J Neurointerv Surg 2020; 13:415-420. [PMID: 32620574 DOI: 10.1136/neurintsurg-2020-016168] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/31/2020] [Accepted: 06/06/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Brain atrophy is associated with an inferior functional outcome in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke. We hypothesized that brain atrophy determined from pre-interventional non-contrast-enhanced CT scans would also be linked to increased mortality in this cohort. METHODS A total of 204 patients treated with MT for acute occlusions of the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (M1) at Tampere University Hospital, Finland between 2013 and 2017 were retrospectively studied. Brain atrophy index (BAI), masseter muscle surface area and density, chronic ischemic lesions, and white matter lesions were evaluated from pre-interventional CT studies. Logistic regression was applied in analyzing the association of BAI with 3-month mortality. RESULTS Median age at baseline was 69.9 years (IQR 15.6) and mortality at 3 months was 13.2% (n=27). BAI, measured with excellent reproducibility (intraclass correlation coefficient ≥0.894, p<0.001), was significantly associated with age (r=0.54), white matter lesions (r=0.43), dental status (r=-0.31), masseter area (r=-0.24), masseter density (r=-0.28), and chronic ischemic lesions (r=0.24) (p≤0.001 for all). In univariable analysis, BAI demonstrated a strong association with mortality (OR 2.02, 95% CI 1.34 to 3.05, per 1 SD increase), and none of the other factors associated with mortality remained as significant when included in the same multivariable model. The results remained similar when extending the follow-up up to 2.5 years. CONCLUSIONS Brain atrophy predicts 3-month mortality after MT of the ICA or the M1 independent of age, masseter sarcopenia, chronic ischemic lesions, or white matter lesions.
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Affiliation(s)
- Iisa Lauksio
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Iisa Lindström
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Niina Khan
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Niko Sillanpää
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Jussi Hernesniemi
- Internal Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Tays Heart Hospital, Tampere University Hospital, Tampere, Finland.,Finnish Cardiovascular Research Center, Tampere University Hospital, Tampere, Finland
| | - Niku Oksala
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland.,Finnish Cardiovascular Research Center, Tampere University Hospital, Tampere, Finland
| | - Sara Protto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
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Lindström I, Protto S, Khan N, Hernesniemi J, Sillanpää N, Oksala N. Association of masseter area and radiodensity with three-month survival after proximal anterior circulation occlusion. J Neurointerv Surg 2020; 13:25-29. [PMID: 32303585 DOI: 10.1136/neurintsurg-2020-015837] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Masseter area (MA), a surrogate for sarcopenia, appears to be useful when estimating postoperative survival, but there is lack of consensus regarding the potential predictive value of sarcopenia in acute ischemic stroke (AIS) patients. We hypothesized that MA and density (MD) evaluated from pre-interventional CT angiography scans predict postinterventional survival in patients undergoing mechanical thrombectomy (MT). MATERIALS AND METHODS 312 patients treated with MT for acute occlusions of the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (M1-MCA) between 2013 and 2018. Median follow-up was 27.4 months (range 0-70.4). Binary logistic (alive at 3 months, OR <1) and Cox regression analyses were used to study the effect of MA and MD averages (MAavg and MDavg) on survival. RESULTS In Kaplan-Meier analysis, there was a significant inverse relationship with both MDavg and MAavg and mortality (MDavg P<0.001, MAavg P=0.002). Long-term mortality was 19.6% (n=61) and 3-month mortality 12.2% (n=38). In multivariable logistic regression analysis at 3 months, per 1-SD increase MDavg (OR 0.61, 95% CI 0.41 to 0.92, P=0.018:) and MAavg (OR 0.57, 95% CI 0.35 to 0.91, P=0.019) were the independent predictors associated with lower mortality. In Cox regression analysis, MDavg and MAavg were not associated with long-term survival. CONCLUSIONS In acute ischemic stroke patients, MDavg and MAavg are independent predictors of 3-month survival after MT of the ICA or M1-MCA. A 1-SD increase in MDavg and MAavg was associated with a 39%-43% decrease in the probability of death during the first 3 months after MT.
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Affiliation(s)
- Iisa Lindström
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sara Protto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Niina Khan
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Jussi Hernesniemi
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Cardiology, Tampere University Hospital, Heart Hospital, Tampere, Finland.,Finnish Cardiovascular Research Center, Tampere University Hospital, Tampere, Finland
| | - Niko Sillanpää
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Niku Oksala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland.,Finnish Cardiovascular Research Center, Tampere University Hospital, Tampere, Finland
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Yuan Z, Chen N, Zhou M, Guo J, Zhang Y, Li Y, He L. Effects of hypertension in patients receiving mechanical thrombectomy: A meta-analysis. Medicine (Baltimore) 2020; 99:e19803. [PMID: 32311996 PMCID: PMC7440350 DOI: 10.1097/md.0000000000019803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Available evidence shows conflicting results with regard to a potential detrimental effect of hypertension on clinical outcomes in patients who undergo mechanical thrombectomy (MT). We performed a meta-analysis to evaluate the impact of hypertension on the prognosis of patients with acute ischaemic stroke (AIS) treated by MT. METHODS We systematically reviewed previous studies in the PubMed, EMBASE, and Cochrane library databases that reported MT outcomes in AIS patients and their relationships with hypertension or blood pressure. We used a poor outcome (modified Rankin score >2 at 3 months) as the primary end point. Mortality and symptomatic intracranial hemorrhage were the secondary end points. We incorporated a random effect for trials in all models. RESULTS Data from 6650 patients in 31 articles that evaluated the effect of hypertension or blood pressure on outcomes after MT were included. Compared with patients without hypertension, patients with hypertension had significantly higher odds of a poor outcome (odds ratio 0.70; 95% confidence interval 0.57-0.85; I = 43%) and higher mortality (odds ratio 1.70; 95% confidence interval 1.26-2.29; I = 33%). Symptomatic intracranial hemorrhage did not differ by patient hypertension status. CONCLUSIONS The present study confirms that hypertension and high blood pressure are associated with a poor outcome at 3 months after MT in AIS patients. However, the causal relationship between hypertension and a poor outcome remains undetermined, and further investigations are required to ascertain whether AIS patients receiving MT could benefit from intensive blood pressure control.
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Affiliation(s)
- Zhengzhou Yuan
- Department of Neurology, West China Hospital of Sichuan University, ChengDu
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Ning Chen
- Department of Neurology, West China Hospital of Sichuan University, ChengDu
| | - Muke Zhou
- Department of Neurology, West China Hospital of Sichuan University, ChengDu
| | - Jian Guo
- Department of Neurology, West China Hospital of Sichuan University, ChengDu
| | - Yanan Zhang
- Department of Neurology, West China Hospital of Sichuan University, ChengDu
| | - Yanbo Li
- Department of Neurology, West China Hospital of Sichuan University, ChengDu
| | - Li He
- Department of Neurology, West China Hospital of Sichuan University, ChengDu
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A prediction model of brain edema after endovascular treatment in patients with acute ischemic stroke. J Neurol Sci 2019; 407:116507. [PMID: 31644991 DOI: 10.1016/j.jns.2019.116507] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Clinical tools predicting brain edema after reperfusion therapy in acute ischemic stroke are scarce. We aim to develop a nomogram model to predict brain edema within the first 24 h after endovascular treatment (EVT) in the anterior cerebral circulation. METHODS A total of 199 patients were retrospectively identified in a single-center stroke registry. Brain edema was measured by midline shift (MLS). The associations between MLS and early neurologic outcomes were described. A nomogram predicting MLS was developed and internally validated. The nomogram was also compared with an available model using the area under the receiver operating characteristic curve (AUC) and decision curve analyses. RESULTS Overall, 87 patients (43.7%) had MLS. The patients with MLS ≥ 6 mm showed progressive neurological deterioration according to repeated measures analysis of variance. Each millimeter increase in MLS was strongly correlated with the presence of in-hospital death or forgoing treatment (Spearman's rho = 0.429, P < .001). Patients with brain edema were less likely to have functional independence at 3 months (19.5% vs. 46.8%, P < .001). A nomogram model including 24-h CT ASPECT scores and cisternal effacement, hypertension and complete recanalization showed a C-index of 0.874. This tool exhibited a higher AUC and higher net benefit than the available model. CONCLUSIONS This study showed a profound association between MLS and early neurologic outcomes. A nomogram model was developed to predict patients at risk of brain edema after EVT in the anterior cerebral circulation.
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Etherton MR, Barreto AD, Schwamm LH, Wu O. Neuroimaging Paradigms to Identify Patients for Reperfusion Therapy in Stroke of Unknown Onset. Front Neurol 2018; 9:327. [PMID: 29867736 PMCID: PMC5962731 DOI: 10.3389/fneur.2018.00327] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/25/2018] [Indexed: 12/17/2022] Open
Abstract
Despite the proven efficacy of intravenous alteplase or endovascular thrombectomy for the treatment of patients with acute ischemic stroke, only a minority receive these treatments. This low treatment rate is due in large part to delay in hospital arrival or uncertainty as to the exact time of onset of ischemic stroke, which renders patients outside the current guideline-recommended window of eligibility for receiving these therapeutics. However, recent pivotal clinical trials of late-window thrombectomy now force us to rethink the value of a simplistic chronological formulation that “time is brain.” We must recognize a more nuanced concept that the rate of tissue death as a function of time is not invariant, that still salvageable tissue at risk of infarction may be present up to 24 h after last-known well, and that those patients may strongly benefit from reperfusion. Multiple studies have sought to address this clinical dilemma using neuroimaging methods to identify a radiographic time-stamp of stroke onset or evidence of salvageable ischemic tissue and thereby increase the number of patients eligible for reperfusion therapies. In this review, we provide a critical analysis of the current state of neuroimaging techniques to select patients with unwitnessed stroke for revascularization therapies and speculate on the future direction of this clinically relevant area of stroke research.
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Affiliation(s)
- Mark R Etherton
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States
| | - Andrew D Barreto
- Stroke Division, Department of Neurology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Lee H Schwamm
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States
| | - Ona Wu
- Department of Neurology, JPK Stroke Research Center, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, MA, United States.,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Charlestown, MA, United States
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Sillanpää N, Pienimäki JP, Protto S, Seppänen J, Numminen H, Rusanen H. Chronic Infarcts Predict Poor Clinical Outcome in Mechanical Thrombectomy of Sexagenarian and Older Patients. J Stroke Cerebrovasc Dis 2018. [PMID: 29525077 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND The impact of lacunar and cortical chronic ischemic lesions (CILs) on the clinical outcome of mechanical thrombectomy (MT) has been little studied. Clinical trials suggest that older patients benefit from MT. We investigated the effect of CILs on the clinical outcome of sexagenarian and older patients with acute middle cerebral artery (MCA) or distal internal carotid artery (ICA) stroke who received MT to treat large-vessel occlusion (LVO). METHODS We prospectively collected the clinical and imaging data of 130 consecutive MT patients of which 68 met the inclusion criteria. We limited the analysis to sexagenarian and older subjects and occlusions no distal than the M2 segment. Baseline clinical, procedural and imaging variables, technical outcome, 24-hour imaging outcome, and the clinical outcome were recorded. Differences between patients with and without CILs were studied with appropriate statistical tests and binary logistic regression analysis. RESULTS Twenty-one patients (31%) had at least 1 CIL. Thirty-eight percent of patients with CIL(s) compared with 62% without (P = .06) experienced good clinical outcome (3-month modified Rankin Scale ≤ 2). A similar nonsignificant trend was seen when lacunar lesions, lesion multiplicity, and chronic white matter lesions were examined separately. Absence of CIL increased the odds of good clinical outcome 3.7-fold (95% confidence interval 1.0-10.7, P = .05) in logistic regression modeling. CONCLUSIONS Chronic cortical and lacunar infarcts in admission imaging are associated with poor clinical outcome in sexagenarian and older patients treated with MT for LVO of the MCA or distal ICA.
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Affiliation(s)
- Niko Sillanpää
- Medical Imaging Center, Tampere University Hospital, Tampere, Finland.
| | | | - Sara Protto
- Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | - Janne Seppänen
- Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | - Heikki Numminen
- Department of Neurology, Tampere University Hospital, Tampere
| | - Harri Rusanen
- Department of Neurology, Oulu University Hospital, Oulu
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