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Prandin G, Valente M, Zhang L, Malhotra P, Sacco S, Foschi M, Ornello R, Pirera E, Toraldo F, Maisano D, Del Regno C, Komauli F, Jaramillo AG, AL‐Karadsheh H, Zahid H, Klein P, Abdalkader M, Manganotti P, Lobotesis K, Nguyen TN, Banerjee S, Gigli GL, Merlino G, D'Anna L. Age-Specific Differences in Inflammatory Biomarkers and Their Impact on Futile Recanalization After Mechanical Thrombectomy: An Inverse Probability Weighting Analysis. Eur J Neurol 2025; 32:e70182. [PMID: 40353608 PMCID: PMC12067390 DOI: 10.1111/ene.70182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2025] [Revised: 04/05/2025] [Accepted: 04/22/2025] [Indexed: 05/14/2025]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) stroke. However, a substantial proportion of patients experience poor functional outcomes despite successful reperfusion, namely futile recanalization (FR). This study aimed to evaluate the predictive value of inflammatory biomarkers, measured on admission and at 24 h, in identifying the risk of FR and to assess age-specific differences influencing this outcome. METHODS This international, multicenter, observational study included patients with anterior circulation LVO stroke treated with MT. Strict inclusion criteria were applied to minimize confounding factors related to inflammation. Inflammatory biomarkers were assessed at admission and 24 h post-procedure. Inverse probability weighting (IPW) was utilized to balance baseline characteristics between patients with FR and effective recanalization (ER). Least absolute shrinkage and selection operator (LASSO) regression was applied to identify independent predictors, and restricted cubic splines were used to determine optimal biomarker cut-offs. RESULTS Among 885 patients, 470 (53%) experienced FR. In multivariate analysis, 24-h CRP (OR 1.01, 95% CI 1.01-1.02, p = 0.018) and 24-h NLR (OR 1.11, 95% CI 1.02-1.22, p = 0.019) were significant predictors of FR, with cut-offs of 8.55 and 4.58, respectively. In patients aged < 80 years, 24-h CRP and NLR were most predictive (cut-offs: 17.09 and 5.59). In patients aged ≥ 80 years, admission SIRI emerged as the most significant predictor (OR 1.24, 95% CI 1.06-1.50, p = 0.015), with an optimal cut-off value of 2.53. CONCLUSIONS Inflammatory biomarkers exhibit significant predictive value for FR following MT, with distinct age-specific patterns. These findings underscore the importance of tailoring predictive models and interventions to optimize clinical outcomes.
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Affiliation(s)
- Gabriele Prandin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health SciencesUniversity Hospital and Health Services of Trieste, ASUGI, University of TriesteTriesteItaly
- Department of Brain SciencesImperial College LondonLondonUK
| | - Mariarosaria Valente
- Stroke UnitUdine University HospitalUdineItaly
- Clinical NeurologyUdine University Hospital and DMED, University of UdineUdineItaly
| | - Liqun Zhang
- Department of NeurologySt George's University of LondonLondonUK
| | | | - Simona Sacco
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'aquilaL'AquilaItaly
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'aquilaL'AquilaItaly
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'aquilaL'AquilaItaly
| | - Edoardo Pirera
- Internal Medicine and Stroke Care Ward, Department of Promoting Health, Maternal‐Infant, Excellence and Internal and Specialized Medicine (ProMISE) “G. D'alessandro”University of PalermoPalermoItaly
| | | | | | | | | | | | | | - Hamza Zahid
- Department of NeurologySt George's University of LondonLondonUK
| | - Piers Klein
- Department of Neurology, RadiologyBoston Medical CenterBostonMassachusettsUSA
| | - Mohamad Abdalkader
- Department of Neurology, RadiologyBoston Medical CenterBostonMassachusettsUSA
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health SciencesUniversity Hospital and Health Services of Trieste, ASUGI, University of TriesteTriesteItaly
| | - Kyriakos Lobotesis
- Neuroradiology, Department of ImagingCharing Cross Hospital, Imperial College London, NHS Healthcare TrustLondonUK
| | - Thanh N. Nguyen
- Department of Neurology, RadiologyBoston Medical CenterBostonMassachusettsUSA
| | - Soma Banerjee
- Department of Brain SciencesImperial College LondonLondonUK
- Department of Stroke and NeuroscienceCharing Cross Hospital, Imperial College Healthcare NHS TrustLondonUK
| | - Gian Luigi Gigli
- Clinical NeurologyUdine University Hospital and DMED, University of UdineUdineItaly
| | - Giovanni Merlino
- Stroke UnitUdine University HospitalUdineItaly
- Clinical NeurologyUdine University Hospital and DMED, University of UdineUdineItaly
| | - Lucio D'Anna
- Department of Brain SciencesImperial College LondonLondonUK
- Department of Stroke and NeuroscienceCharing Cross Hospital, Imperial College Healthcare NHS TrustLondonUK
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Levee V, Valente M, Bax F, Zhang L, Sacco S, Foschi M, Ornello R, Chulack K, Marchong E, Sheikh F, Fayez F, Del Regno C, Aggour M, Sponza M, Toraldo F, Algazlan R, Lobotesis K, Bagatto D, Mansoor N, Kalladka D, Gavrilovic V, Deana C, Bassi F, Stewart B, Gigli GL, Banerjee S, Merlino G, D’Anna L. Outcomes of different anesthesia techniques in nonagenarians treated with mechanical thrombectomy for anterior circulation large vessel occlusion: An inverse probability weighting analysis. Eur Stroke J 2024:23969873241293009. [PMID: 39474896 PMCID: PMC11556564 DOI: 10.1177/23969873241293009] [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: 07/08/2024] [Accepted: 10/07/2024] [Indexed: 11/14/2024] Open
Abstract
INTRODUCTION There is a lack of evidence for the optimal type of anesthesia technique in patients ⩾ 90 years with acute ischemic stroke undergoing mechanical thrombectomy (MT) as this subgroup of patients was often excluded or under-represented in previous trials. We aimed to compare outcomes between general anesthesia (GA) and non-GA techniques in patients ⩾ 90 years with large vessel occlusion (LVO) undergoing MT. PATIENTS AND METHODS Our study included patients ⩾ 90 years with anterior circulation LVO, NIHSS ⩾ 6, ASPECTS ⩾ 5 consecutively treated with MT within 6 h after stroke onset in three thrombectomy capable centers between January 1st, 2016 and March 30th, 2023. Inverse probability weighting (IPW) was used to reduce bias by indication of the anesthesia type on study outcomes. We used a weighted ordinal robust logistic regression analysis to explore the primary outcome of modified Rankin Scale (mRS) shift at 90 days in GA versus non-GA treated patients. Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (sICH) and TICI score of 2b, 2c, or 3. RESULTS We included 139 patients ⩾ 90 years treated with MT, 62 were in GA group and 77 in non-GA group. There was a significant shift for worse mRS scores at 90-day in non-GA treated patients (cOR 3.65, 95% CI 1.77-7.77, p = 0.001). The weighted logistic regression showed that non-GA technique was an independent predictor of 90-day mortality (OR 7.49, 95% CI 2.00-28.09; p = 0.003). CONCLUSION Our study indicated that nonagenarians with acute ischemic stroke treated with MT without GA have a worse prognosis than their counterparts undergoing MT with GA. Further studies in larger cohorts are warranted to evaluate the optimal type of anesthesia in this patient population.
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Affiliation(s)
- Viva Levee
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mariarosaria Valente
- Stroke Unit, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital and DMED, University of Udine, Udine, Italy
| | - Francesco Bax
- Stroke Unit, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital and DMED, University of Udine, Udine, Italy
| | - Liqun Zhang
- Department of Neuroscience, George’s University of London, Stroke, London, UK
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Katherine Chulack
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Emma Marchong
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Fahad Sheikh
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Feras Fayez
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Caterina Del Regno
- Stroke Unit, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital and DMED, University of Udine, Udine, Italy
| | - Mohammed Aggour
- Department of Neuroscience, George’s University of London, Stroke, London, UK
| | | | - Francesco Toraldo
- Stroke Unit, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital and DMED, University of Udine, Udine, Italy
| | - Razan Algazlan
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kyriakos Lobotesis
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Nina Mansoor
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Dheeraj Kalladka
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Anaesthesia and Intensive Care Health Integrated, Agency of Friuli Centrale, Udine, Italy
| | | | - Cristian Deana
- Department of Anaesthesia and Intensive Care Health Integrated, Agency of Friuli Centrale, Udine, Italy
| | - Flavio Bassi
- Department of Anaesthesia and Intensive Care Health Integrated, Agency of Friuli Centrale, Udine, Italy
| | - Berry Stewart
- Department of Anaesthesia, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Gian Luigi Gigli
- Clinical Neurology, Udine University Hospital and DMED, University of Udine, Udine, Italy
| | - Soma Banerjee
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
| | - Giovanni Merlino
- Stroke Unit, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital and DMED, University of Udine, Udine, Italy
| | - Lucio D’Anna
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
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D’Anna L, Abu‐Rumeileh S, Merlino G, Ornello R, Foschi M, Diana F, Barba L, Mastrangelo V, Romoli M, Lobotesis K, Bax F, Kuris F, Valente M, Otto M, Korompoki E, Sacco S, Gigli GL, Nguyen TN, Banerjee S. Safety and Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Attributable to Cardiological Diseases: A Scoping Review. J Am Heart Assoc 2024; 13:e034783. [PMID: 38874062 PMCID: PMC11646491 DOI: 10.1161/jaha.124.034783] [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] [Indexed: 06/15/2024]
Abstract
There is limited evidence on the outcomes and safety of mechanical thrombectomy (MT) among patients with acute ischemic stroke (AIS) in the context of cardiac diseases. Our study reviews MT in AIS within the context of cardiac diseases, aiming to identify existing and emerging needs and gaps. PubMed and Scopus were searched until December 31, 2023, using a combination of cardiological diseases and "mechanical thrombectomy" or "endovascular treatment" as keywords. Study design included case reports/series, observational studies, randomized clinical trials, and meta-analyses/systematic reviews. We identified 943 articles, of which 130 were included in the review. Results were categorized according to the cardiac conditions. MT shows significant benefits in patients with atrial fibrillation (n=139) but lacks data for stroke occurring after percutaneous coronary intervention (n=2) or transcatheter aortic valve implantation (n=5). MT is beneficial in AIS attributable to infective endocarditis (n=34), although functional benefit may be limited. Controversy surrounds the functional outcomes and mortality of patients with AIS with heart failure undergoing MT (n=11). Despite technical challenges, MT appears feasible in aortic dissection cases (n=4), and in patients with left ventricular assist device or total artificial heart (n=10). Data on AIS attributable to congenital heart disease (n=4) primarily focus on pediatric cases requiring technical modifications. Treatment outcomes of MT in patients with cardiac tumors (n=8) vary because of clot consistency differences. After cardiac surgery stroke, MT may improve outcomes with early intervention (n=13). Available data outline the feasibility of MT in patients with AIS attributable to large-vessel occlusion in the context of cardiac diseases.
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Affiliation(s)
- Lucio D’Anna
- Department of Stroke and NeuroscienceCharing Cross Hospital, Imperial College London NHS Healthcare TrustLondonUnited Kingdom
- Department of Brain SciencesImperial College LondonLondonUnited Kingdom
| | - Samir Abu‐Rumeileh
- Department of NeurologyMartin‐Luther‐University Halle‐WittenbergHalle (Saale)Germany
| | - Giovanni Merlino
- Stroke Unit and Clinical NeurologyUdine University HospitalUdineItaly
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Francesco Diana
- Interventional NeuroradiologyVall d’Hebron University HospitalBarcelonaCatalunyaSpain
| | - Lorenzo Barba
- Department of NeurologyMartin‐Luther‐University Halle‐WittenbergHalle (Saale)Germany
| | | | - Michele Romoli
- Neurology and Stroke Unit, Department of NeuroscienceBufalini Hospital, Azienda Unità Sanitaria Locale RomagnaCesenaItaly
| | - Kyriakos Lobotesis
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College LondonNHS Healthcare TrustLondonUnited Kingdom
| | - Francesco Bax
- Philip Kistler Research Center, Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Fedra Kuris
- Stroke Unit and Clinical NeurologyUdine University HospitalUdineItaly
| | - Mariarosaria Valente
- Clinical NeurologyUdine University Hospital and Dipartmento di Area Medica, University of UdineUdineItaly
| | - Markus Otto
- Department of NeurologyMartin‐Luther‐University Halle‐WittenbergHalle (Saale)Germany
| | - Eleni Korompoki
- Department of Brain SciencesImperial College LondonLondonUnited Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical SciencesUniversity of L’AquilaL’AquilaItaly
| | - Gian Luigi Gigli
- Stroke Unit and Clinical NeurologyUdine University HospitalUdineItaly
| | - Thanh N. Nguyen
- Department of Neurology, RadiologyBoston Medical CenterBostonMAUSA
| | - Soma Banerjee
- Department of Stroke and NeuroscienceCharing Cross Hospital, Imperial College London NHS Healthcare TrustLondonUnited Kingdom
- Department of Brain SciencesImperial College LondonLondonUnited Kingdom
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Enriquez BAB, Halling HK, Lund CG, Tennøe B, Brunborg C, Skjelland ME, Aamodt AH, Skagen K. Exploring the Impact of Age and Pre-Stroke Modified Rankin Scale in Elderly Thrombectomy: A 15-Year Single-Center Experience. Cerebrovasc Dis Extra 2024; 14:125-133. [PMID: 39191213 PMCID: PMC11521515 DOI: 10.1159/000540992] [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: 03/06/2024] [Accepted: 07/30/2024] [Indexed: 08/29/2024] Open
Abstract
INTRODUCTION The selection of endovascular thrombectomy (EVT) for acute ischemic stroke in the elderly remains challenging due to the underrepresentation of these patients in landmark randomized trials. The aim of this study was to assess the association between age and the pre-stroke modified Rankin scale score with functional outcomes after EVT in elderly patients aged ≥80 years. METHODS We prospectively collected data from consecutive elderly patients who underwent EVT of the anterior or posterior circulation at our institution between 2007 and 2022. Clinical and radiological parameters were analyzed using a fair outcome (mRS ≤3 or retained pre-stroke mRS score of 4) as the primary outcome. RESULTS In total, 307 elderly patients were included in the analysis. Fair functional outcomes were achieved in 162 (53%) patients. Eighty-four (27.4%) patients were deceased at 3-month follow-up and the mortality rate increased to 37.1% (114 deceased) at 1-year follow-up. The likelihood of achieving a fair functional outcome decreased by 8% for every 1-year age increase (OR 0.81, 95% CI 0.73-0.90). Lower National Institutes of Health Stroke Scale (OR 0.89, 95% CI 0.85-0.93, p < 0.001) and pre-stroke mRS (OR 0.67, 95% CI 0.53-0.84, p < 0.001) were associated with fair outcomes. CONCLUSIONS EVT in elderly patients with stroke is beneficial in selected cases. Increasing age was associated with an increased risk of an mRS change to 4 or worse and death within 1 year. The pre-stroke mRS may aid clinicians in the selection of elderly patients for EVT.
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Affiliation(s)
- Brian Anthony B. Enriquez
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | - Bjørn Tennøe
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Mona Elisabeth Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway
| | - Karolina Skagen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
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Jiang X, Wang J, Hu Y, Lang H, Bao J, Chen N, He L. Is endovascular treatment still good for acute ischemic stroke in the elderly? A meta-analysis of observational studies in the last decade. Front Neurosci 2024; 17:1308216. [PMID: 38249587 PMCID: PMC10796798 DOI: 10.3389/fnins.2023.1308216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Background The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for endovascular treatment (EVT) in elderly patients. This meta-analysis aims to evaluate the therapeutic effects of endovascular treatment for acute ischemic stroke in the elderly compared with younger patients. Methods Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT in elderly patients and those aged <80 years. The primary outcome was functional independence, defined as mRS 0-2 at 90 days after EVT. The secondary outcomes were the rate of successful recanalization, symptomatic intracranial hemorrhage (sICH) and mortality. Odds ratios (ORs) were estimated using a random effects model. Results In total, twenty-six studies with 9,492 enrolled participants were identified. Our results showed that, compared with patients aged <80 years undergoing EVT, EVT was associated with a lower rate of functional independence at 90 days (OR = 0.38; 95% CI, 0.33-0.45; p < 0.00001) and a higher mortality rate (OR = 2.51; 95% CI, 1.98-3.18; p < 0.00001) in the elderly. Furthermore, even without a significantly observed increase in sICH (OR = 1.19; 95% CI, 0.96-1.47; p = 0.11), EVT appeared to be associated with a lower rate of successful recanalization (OR = 0.81; 95% CI, 0.68-0.96; p = 0.02). Conclusion Evidence from observational studies revealed that EVT has less functional outcomes in elderly patients with acute ischemic stroke. Further studies are needed to better identify patients aged ≥80 years who could potentially benefit from EVT.
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Affiliation(s)
| | | | | | | | | | - Ning Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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