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Liang W, Kwan ATH, Ye H, Mofatteh M, Feng M, Wellington J, Fu P, Wei W, Sun Y, Huang J, Luo J, Chen Y, Yang S, Zhou S. Post-ASPECTS and Post-PC-ASPECTS Predict the Outcome of Anterior and Posterior Ischemic Stroke Following Thrombectomy. Risk Manag Healthc Policy 2023; 16:2757-2769. [PMID: 38130745 PMCID: PMC10733595 DOI: 10.2147/rmhp.s436661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
Purpose In this study, we aimed to determine whether post-Alberta Stroke Project Early CT Changes Score (post-ASPECTS) in anterior stroke and post-(posterior circulation) PC-ASPECTS in posterior stroke on CT can predict post-endovascular thrombectomy (EVT) functional outcomes among patients with acute ischemic stroke (AIS) after EVT. Patients and Methods A total of 247 consecutive patients aged 18 and over receiving EVT for LVO-related AIS were recruited into a prospective database. The data was retrospectively analyzed between March 2019 and February 2022 from two comprehensive tertiary care stroke centers: Foshan Sanshui District People's Hospital and First People's Hospital of Foshan in China. Patient parameters included EVT within 24 hr of symptom onset, premorbid modified Rankin scale (mRS) ≤2, presence of distal and terminal cerebral blood vessel occlusion, and subsequent 24-72-hr post-stroke onset CT scan. Univariate comparisons were performed using the Fisher's exact test or χ2 test for categorical variables and the Mann-Whitney U-test for continuous variables. Logistic regression analysis was performed to further analyze for adjusting for confounding factors. A p-value of ≤0.05 was statistically significant. Results Overall, 236 individuals with 196 anterior circulation ischemic strokes and 40 posterior strokes of basilar artery occlusion were examined. Post-ASPECTS in anterior stroke and post-pc-ASPECTS as strong positive markers of favorable outcome at 90 days post-EVT; and lower rates of inpatient mortality/hospice discharge, 90-day mortality, and 90-day poor outcome were observed. Moreover, patients in the post-ASPECTS ≥ 7 cohort experienced shorter door-to-recanalization time (DRT), puncture-to-recanalization time (PRT), and last known normal-to-puncture time (LKNPT). Conclusion Post-ASPECTS ≥7 in anterior circulation AIS and post-pc-ASPECTS ≥7 in posterior circulation can serve as strong prognostic markers of functional outcome after EVT.
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Affiliation(s)
- Wenjun Liang
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, People’s Republic of China
| | - Angela T H Kwan
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Huifang Ye
- Department of Pharmacy, Foshan Sanshui District People’s Hospital, Foshan, People’s Republic of China
| | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - Mingzhu Feng
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, People’s Republic of China
| | - Jack Wellington
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Pingzhong Fu
- Department of Radiology, Foshan Sanshui District People’s Hospital, Foshan, Guangdong Province, People’s Republic of China
| | - Wenlong Wei
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, People’s Republic of China
| | - Yu Sun
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, People’s Republic of China
| | - Jianhui Huang
- Department of Surgery of Cerebrovascular Diseases, First People’s Hospital of Foshan, Foshan, Guangdong Province, People’s Republic of China
| | - Jie Luo
- Department of Surgery of Cerebrovascular Diseases, First People’s Hospital of Foshan, Foshan, Guangdong Province, People’s Republic of China
| | - Yimin Chen
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, People’s Republic of China
| | - Shuiquan Yang
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, People’s Republic of China
| | - Sijie Zhou
- Department of Surgery of Cerebrovascular Diseases, First People’s Hospital of Foshan, Foshan, Guangdong Province, People’s Republic of China
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Lin MT, Wu HW, Chen HY, Tsai HT, Wu CH. Association of clinical factors to functional outcomes in patients with stroke with large-vessel occlusion after endovascular thrombectomy. J Formos Med Assoc 2023; 122:344-350. [PMID: 36513530 DOI: 10.1016/j.jfma.2022.11.016] [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: 10/17/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/PURPOSE Multiple clinical factors have been reported to be associated with functional outcomes in patients with stroke. However, little is known about prognostic predictors of functional independence in patients with stroke undergoing endovascular thrombectomy (EVT). Our study aimed to investigate the correlation between multiple prognostic variables (including EVT and rehabilitation-related parameters) and functional outcomes in patients post-EVT. METHODS This retrospective cohort study recruited patients hospitalized between December 2018 and March 2022. Patients with stroke with large-vessel occlusion who underwent EVT were eligible for inclusion in the study. Prognostic factors, including premorbid characteristics, laboratory data, EVT- and rehabilitation-related parameters, functional activity level, balance ability, swallowing, and sphincter function, were collected. Logistic regression and generalized linear models were used to analyze their correlations with functional outcomes. RESULTS A total of 148 patients were included. In the univariate logistic regression analysis, younger age, premorbid functional independence, higher hemoglobin (Hb) level, lower National Institute of Health Stroke Scale (NIHSS) score, absence of hemorrhagic transformation in 14 days, no nasogastric (NG) tube placement, earlier rehabilitation, frequent daily rehabilitation sessions, more out-of-bed rehabilitation, better ability of sitting up, better initial sitting balance, higher Barthel index (BI), absence of immobility, and neurological complications were associated with favorable outcomes at 3 months. In the stepwise regression model, the predictors of favorable function at 3 months included age, ability to sit up, and frequency of daily rehabilitation sessions; favorable outcomes at 6 months were associated with age, ability to sit up, and swallowing function. CONCLUSION In patients with stroke post-EVT, better functional outcomes were associated with prognostic variables, including younger age, better ability to sit up, normal swallowing function, and frequent daily rehabilitation sessions.
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Affiliation(s)
- Meng-Ting Lin
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Hao-Wei Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Hsing-Yu Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Hsiao-Ting Tsai
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chueh-Hung Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100, Taiwan.
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Nguyen HA, Vu DL, Nguyen QA, Mai DT, Tran AT, Le HK, Nguyen TT, Nguyen TT, Tran C, Dao VP, Pierot L. Predictive Factors for Clinical Outcome After Direct Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion Within 4.5 h. Front Neurol 2022; 13:895182. [PMID: 35847212 PMCID: PMC9280660 DOI: 10.3389/fneur.2022.895182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRecent trials including DIRECT-MT, DEVT, and SKIP have found that direct mechanical thrombectomy (MT) is equally effective as the combination of MT and intravenous thrombolysis. However, the results of the other trials, namely MR-CLEAN NO-IV and the SWIFT-DIRECT trial have failed to confirm the non-inferiority of direct MT vs. the combination therapy.AimWe aimed to identify prognostic factors of direct MT for anterior circulation large vessel occlusion within 4.5 h.Materials and MethodsData from January 2018 to January 2022 were retrospectively collected and analyzed. Adult patients with confirmed anterior circulation large vessel occlusion within 4.5 h of onset with baseline NIHSS of ≥6 and baseline ASPECTS of ≥6 treated using direct MT within 6 h were recruited.ResultsA total of 140 patients were enrolled in the study with a median age of 65.5 years [interquartile range (IQR), 59–76.5], median baseline NIHSS of 13.5 (IQR, 11–16), and median baseline ASPECTS of 8 (IQR, 7–8). Direct MT was feasible in all patients (100%). Successful reperfusion (mTICI 2b-3) was achieved in 124/140 patients (88.6%) with a low rate of complications (8/140, 5.7%). Any type of intracranial hemorrhage (ICH) and symptomatic ICH occurred in 44/140 (31.4%) and 5/140 (3.6%), respectively. Overall, a good outcome (mRS 0–2) was achieved in 93/140 (66.4%), and the mortality rate was 9.3% (13/140 patients). Using multivariate analysis, lower age [odds ratio (OR), 0.96; 95% CI, 0.92–1.00; P = 0.05], low baseline NIHSS (OR, 0.82; 95% CI, 0.74–0.92; P = 0.00), and absence of ICH (OR, 0.29; 95% CI, 0.10–0.81; P = 0.02) were independently associated with favorable outcome. Independent predictors of mortality were baseline NIHSS (OR, 1.21; 95% CI, 1.01–1.46; P = 0.04), successful reperfusion (OR, 0.02; 95% CI, 0.00–0.58; P = 0.02), and ICH (OR, 0.12; 95% CI, 0.02–0.75; P = 0.02). Further analysis showed that the median mRS at 90 days was significantly better in the MCA occlusion group compared to the ICA plus M1 occlusion group [1 (IQR 0–3) vs. 2 (IQR 1–4); P = 0.05].ConclusionsOur findings suggest that direct thrombectomy may be an adequate clinical option for younger patients (≤70) experiencing proximal middle artery occlusion within 4.5 h and who have low baseline NIHSS (≤14).
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Affiliation(s)
- Huu An Nguyen
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
- *Correspondence: Huu An Nguyen
| | - Dang Luu Vu
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Quang Anh Nguyen
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Duy Ton Mai
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam
| | | | | | | | | | - Cuong Tran
- Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
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Gao J, Wen C, Sun J, Chen D, Zhang D, Wang N, Liu Y, Wang J, Zhang B. Prognostic factors for acute posterior circulation cerebral infarction patients after endovascular mechanical thrombectomy: A retrospective study. Medicine (Baltimore) 2022; 101:e29167. [PMID: 35512073 PMCID: PMC9276263 DOI: 10.1097/md.0000000000029167] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/06/2022] [Indexed: 01/04/2023] Open
Abstract
This article was to analyze the factors influencing the prognosis of posterior circulation cerebral infarction (PCCI) patients, retrospectively.One hundred forty five patients diagnosed with PCCI in Nanyang Central Hospital between June 25, 2016 and October 14, 2019 were included and underwent cerebral vascular mechanical thrombectomy. The clinical data of those patients were collected. The patients were followed up for 3 months to observe the prognostic efficacy and explore the influencing factors for poor prognosis. The potential prognostic factors for PCCI patients after emergency endovascular mechanical thrombectomy were analyzed by univariate and multivariable logistic regression. The thermodynamic diagram was drawn to explore the associations between the prognostic factors.The risk of poor prognosis in PCCI patients receiving emergency endovascular mechanical thrombectomy was reduced by 0.552 time with every 1-point increase of the Alberta Stroke Program Early CT in posterior circulation score (odds ratio [OR] = 0.448, 95% confidence interval [CI]: 0.276-0.727). The risk of poor prognosis was increased by 0.827 time for each additional grade in the digital subtraction angiography-American Society of Intervention and Therapeutic Neuroradiology grading (OR = 1.827, 95% CI: 1.221-2.733, P = .003) and increased by 0.288 time for every 1-point increase in National Institutes of Health Stroke scale at 24 hours (OR = 1.288, 95% CI: 1.161-1.429). All P < .05.Alberta Stroke Program Early CT in posterior circulation score, digital subtraction angiography-American Society of Intervention and Therapeutic Neuroradiology grading, National Institutes of Health Stroke scale score at 24 hours were factors affecting the prognosis of PCCI patients undergoing emergency endovascular mechanical thrombectomy, which might provide evidence for endovascular treatment of PCCI.
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Ha SW, Lee CH, Kim HS, Yeon EK, Lee SJ, Shin BS, Kang HG. Factors Distinguishing Proximal and Distal Internal Carotid Artery Occlusions in Patients with Acute Ischemic Stroke. Diagnostics (Basel) 2022; 12:diagnostics12020494. [PMID: 35204581 PMCID: PMC8871289 DOI: 10.3390/diagnostics12020494] [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: 12/27/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 12/03/2022] Open
Abstract
Acute internal carotid artery (ICA) occlusions cause extensive brain ischemia. Accurate determination of the occlusion site facilitates rapid revascularization interventions and improves prognosis. However, proximal ICA occlusions, as determined with computed tomography (CT) angiography, often are located more distally. Therefore, we assessed clinical and imaging factors associated with the accurate determination of occlusion sites. In this observational study, we evaluated 102 patients who presented acute ischemic stroke symptoms and had a CT angiography within 6 h, showing proximal ICA occlusion. The participants were divided into two groups, depending on whether there was correspondence between digital subtraction angiography and CT angiography regarding the occlusion location. Proximal occlusions were, accordingly, categorized as “true” (correspondence) or “false” (no correspondence; distal). Demographic, clinical, and imaging features were analyzed. Multivariate regression analysis was performed to identify factors predicting the correspondence between actual ICA occlusion sites and those detected by CT angiography. The shape (Odds ratios, OR = 646.584; Confidence interval, CI = 21.703–19263.187; p < 0.001) and the length (OR = 0.696; CI = 0.535–0.904; p = 0.007) of the ICA occlusion and atrial fibrillation (OR = 0.024; CI = 0.002–0.340; p = 0.006) were significant factors. The cut-off length of ICA stump at 6.2 mm, the sensitivity was 71%, and the specificity was 70% (area under the ROC curve = 0.767).
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Affiliation(s)
- Sang Woo Ha
- Department of Neurosurgery, Chosun University Medical School, Gwangju 61453, Korea; (S.W.H.); (H.S.K.)
| | - Chan-Hyuk Lee
- Department of Neurology, Jeonbuk National University Hospital, Jeonju 54907, Korea; (C.-H.L.); (B.-S.S.)
- Department of Neurology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Korea
| | - Hak Sung Kim
- Department of Neurosurgery, Chosun University Medical School, Gwangju 61453, Korea; (S.W.H.); (H.S.K.)
| | - Eung Koo Yeon
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea;
| | - Seung Jae Lee
- Department of Chemistry, Institute for Molecular Biology and Genetics, Jeonbuk National University, Jeonju 54896, Korea;
| | - Byoung-Soo Shin
- Department of Neurology, Jeonbuk National University Hospital, Jeonju 54907, Korea; (C.-H.L.); (B.-S.S.)
- Department of Neurology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Korea
| | - Hyun Goo Kang
- Department of Neurology, Jeonbuk National University Hospital, Jeonju 54907, Korea; (C.-H.L.); (B.-S.S.)
- Department of Neurology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Korea
- Correspondence: ; Tel.: +82-063-259-3161
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Comparative Studies of Cerebral Reperfusion Injury in the Posterior and Anterior Circulations After Mechanical Thrombectomy. Transl Stroke Res 2022; 13:556-564. [PMID: 35006533 PMCID: PMC9232466 DOI: 10.1007/s12975-021-00977-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
Cerebral reperfusion injury is the major complication of mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Contrast extravasation (CE) and intracranial hemorrhage (ICH) are the key radiographical features of cerebral reperfusion injury. The aim of this study was to investigate CE and ICH after MT in the anterior and posterior circulation, and their effect on functional outcome. This is a retrospective study of all consecutive patients who were treated with MT for AIS at University of California Irvine Medical Center between January 1, 2014, and December 31, 2017. Patient characteristics, clinical features, procedural variables, contrast extravasation, ICH, and outcomes after MT were analyzed. A total of 131 patients with anterior circulation (AC) stroke and 25 patients with posterior circulation (PC) stroke underwent MT during the study period. There was no statistically significant difference in admission NIHSS score, blood pressure, rate of receiving intravenous tPA, procedural variables, contrast extravasation, and symptomatic ICH between the 2 groups. Patients with PC stroke had a similar rate of favorable outcome (mRS 0–2) but significantly higher mortality (40.0% vs. 10.7%, p < 0.01) than patients with AC stroke. Multivariate regression analysis identified initial NIHSS score (OR 1.1, CI 1.0–1.2, p = 0.01), number of passes with stent retriever (OR 2.1, CI 1.3–3.6, p < 0.01), and PC stroke (OR 9.3, CI 2.5–35.1, p < 0.01) as independent risk factors for death. There was no significant difference in functional outcomes between patients with and without evidence of cerebral reperfusion injury after MT. We demonstrated that AC and PC stroke had similar rates of cerebral reperfusion injury and favorable outcome after MT. Cerebral reperfusion injury is not a significant independent risk factor for poor functional outcome.
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Szmygin M, Sojka M, Tarkowski P, Pyra K, Luchowski P, Wojczal J, Ficek R, Drelich-Zbroja A, Jargiełło T. Predictors of favorable outcome after endovascular thrombectomy for acute ischemic stroke due to large vessel occlusion in young patients. Acta Radiol 2021; 63:1689-1694. [PMID: 34766505 DOI: 10.1177/02841851211056476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) became a standard of care for patients with acute ischemic stroke (AIS) with its efficacy demonstrated by meta-analysis and randomized studies. Although ischemic stroke is associated more with older patients, it may also have devastating neurological effects on young patients. PURPOSE To present our experience with stroke patients aged <50 years treated with endovascular means and to evaluate clinical and procedural factors associated with outcome and mortality. MATERIAL AND METHODS This study was conducted on 34 young stroke patients treated with MT. Clinical features including baseline results, radiological imaging, procedural details, and outcome results were documented and evaluated. Recanalization was assessed according to the TICI score. The clinical condition was evaluated after three months using mRS. Mortality rate was calculated. RESULTS The rate of successful recanalization (TICI ≥2c) was 79% (27/34). Symptomatic intracranial hemorrhage (sICH) was observed in 5 (15%) patients. After 90 days, the mortality rate was 12%. Favorable clinical outcome (mRs 0-2) was regained in 65% of the patients whereas satisfactory clinical outcome was seen in 85%. Poor clinical outcome (mRs >2) was observed in 9 (23.7%) patients. CONCLUSION In conclusion, the results of this study demonstrate that MT for AIS in young patients is feasible and provides an excellent rate of arterial recanalization and high rate of favorable outcomes. Statistical analysis showed that shorter time from onset to arrival and reperfusion, successful recanalization and absence of hemorrhagic transformation are the predictors of favorable clinical outcome and overall survival rate.
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Affiliation(s)
- Maciej Szmygin
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Lubelskie, Poland
| | - Michał Sojka
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Lubelskie, Poland
| | - Piotr Tarkowski
- Medical University of Lublin, Department of Radiology and Nuclear Medicine, Lublin, Lubelskie, Poland
| | - Krzysztof Pyra
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Lubelskie, Poland
| | - Piotr Luchowski
- Medical University of Lublin, Department of Neurology, Lublin, Lubelskie, Poland
| | - Joanna Wojczal
- Medical University of Lublin, Department of Neurology, Lublin, Lubelskie, Poland
| | - Remigiusz Ficek
- Medical University of Lublin, Department of Neurology, Lublin, Lubelskie, Poland
| | - Anna Drelich-Zbroja
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Lubelskie, Poland
| | - Tomasz Jargiełło
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Lubelskie, Poland
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Gigliotti MJ, Sweid A, El Naamani K, Patel N, Cockroft KM, Park C, Kanekar S, Church EW, Tjoumakaris SI, Simon SD. Management of Internal Carotid Artery and Intracranial Anterior Circulation Tandem Occlusion with Stenting versus No Stenting: A Multicenter Study. World Neurosurg 2021; 153:e237-e243. [PMID: 34175489 DOI: 10.1016/j.wneu.2021.06.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs. METHODS This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis. RESULTS There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20-3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016-2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160-15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529-37.4; P = 0.003). CONCLUSIONS Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement.
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Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Neel Patel
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christian Park
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Sangam Kanekar
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Scott D Simon
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Yeo LLL, Chen VHE, Leow AST, Meyer L, Fiehler J, Tu TM, Tham CH, Sia CH, Jamous A, Behme D, Kastrup A, Papanagiotou P, Styczen H, Forsting M, Lee TH, Chu CL, Fischer S, Maus V, Abdullayev N, Kabbasch C, Mönch S, Maegerlein C, Arnberg F, Andersson T, Holmin S, Teoh HL, Paliwal P, Ahmad A, Gopinathan A, Yang C, Seet RCS, Chan BPL, Sharma VK, Tan BYQ. Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: A real-world multicenter experience. Eur J Neurol 2021; 28:2736-2744. [PMID: 33960072 DOI: 10.1111/ene.14899] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022]
Abstract
Endovascular thrombectomy (EVT) is the standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO). Young patients with AIS-LVO have distinctly different underlying stroke mechanisms and etiologies. Much is unknown about the safety and efficacy of EVT in this population of young AIS-LVO patients. All consecutive AIS-LVO patients aged 50 years and below were included in this multicenter cohort study. The primary outcome measured was functional recovery at 90 days, with modified Rankin Scale of 0-2 deemed as good functional outcome. A total of 275 AIS-LVO patients that underwent EVT from 10 tertiary centers in Germany, Sweden, Singapore, and Taiwan were included. Successful reperfusion was achieved in 85.1% (234/275). Good functional outcomes were achieved in 66.0% (182/275). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%). National Institutes of Health Stroke Scale (NIHSS) score at presentation was inversely related to good functional outcomes (aOR: 0.92, 95% CI: 0.88-0.96 per point increase, p < 0.001). Successful reperfusion (aOR: 3.22, 95% CI: 1.44-7.21, p = 0.005), higher ASPECTS (aOR: 1.21, 95% CI: 1.01-1.44, p = 0.036), and bridging intravenous thrombolysis (aOR: 2.37, 95% CI: 1.29-4.34, p = 0.005) independently predicted good functional outcomes. Successful reperfusion was inversely associated with in-hospital mortality (aOR: 0.14, 95% CI: 0.03-0.57, p = 0.006). History of hypertension strongly predicted in-hospital mortality (aOR: 4.59, 95% CI: 1.10-19.13, p = 0.036). While differences in functional outcomes exist across varying stroke aetiologies, high rates of successful reperfusion and good outcomes are generally achieved in young AIS-LVO patients undergoing EVT.
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Affiliation(s)
- Leonard Leong-Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vanessa Hui En Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Aloysius Sheng-Ting Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tian-Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore City, Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, Singapore City, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Center, Singapore City, Singapore
| | - Ala Jamous
- Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Daniel Behme
- Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany.,Areteion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Hanna Styczen
- Institute of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Tsong-Hai Lee
- Stroke Section, Department of Neurology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chan-Lin Chu
- Stroke Section, Department of Neurology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Sebastian Fischer
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Bochum-Langendreer, Bochum, Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Bochum-Langendreer, Bochum, Germany
| | - Nuran Abdullayev
- Institute of Radiology and Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Institute of Radiology and Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hock-Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Prakash Paliwal
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Aftab Ahmad
- Division of Neurology, Ng Teng Fong Hospital, Singapore City, Singapore
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
| | - Raymond Chee-Seong Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Bernard Poon-Lap Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
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Post-stroke infection in acute ischemic stroke patients treated with mechanical thrombectomy does not affect long-term outcome. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:452-459. [PMID: 33598019 PMCID: PMC7863840 DOI: 10.5114/aic.2020.101771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/04/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction The impact of an infection that requires antibiotic treatment (IRAT) after an acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT) remains unclear. Aim Here, we studied the prevalence and the profile of IRAT in patients with AIS treated with MT, aiming to identify predictive factors and prognostic implications at 90 days after stroke. Material and methods We analyzed parameters available within 24 h after AIS including demographics, risk factors, National Institutes of Health Stroke Scale (NIHSS) upon admission and 24 h later, hemorrhagic transformation (HT) on computed tomography, and several clinical and biochemical markers. The outcome measures were the modified Rankin Scale (mRS) 0-2 and 90 days post-stroke mortality. Results We included 291 patients; in 184 (63.2%) patients MT was preceded by intravenous thrombolysis (IVT), and 83 (28.5%) patients developed IRAT. Multivariate analysis showed that male sex and hemorrhagic transformation on CT taken 24 h after stroke increased the risk of IRAT. We found that younger age, male sex, lower delta NIHSS, shorter time from stroke onset to groin puncture, better recanalization and a lack of hemorrhagic transformation on CT taken 24 h after stroke favorably affected outcome at day 90. Multivariate analysis showed that older age, higher delta NIHSS, unknown stroke etiology and lack of treatment with IVT were independent predictors of death up to day 90. Infection that required antibiotic treatment did not enter in the models for the studied outcome measures. Conclusions In AIS patients treated with MT, IRAT is not an independent factor that affects favorable outcome or mortality 90 days after stroke.
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Buchman SL, Merkler AE. Basilar Artery Occlusion: Diagnosis and Acute Treatment. Curr Treat Options Neurol 2019; 21:45. [DOI: 10.1007/s11940-019-0591-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Nawabi J, Kniep H, Schön G, Flottmann F, Leischner H, Kabiri R, Sporns P, Kemmling A, Thomalla G, Fiehler J, Broocks G, Hanning U. Hemorrhage After Endovascular Recanalization in Acute Stroke: Lesion Extent, Collaterals and Degree of Ischemic Water Uptake Mediate Tissue Vulnerability. Front Neurol 2019; 10:569. [PMID: 31214107 PMCID: PMC6558047 DOI: 10.3389/fneur.2019.00569] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/15/2019] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose: Intracranial hemorrhage (ICH) remains a major complication of endovascular treatment (ET) in acute stroke. The aim of this study was to identify clinical and imaging predictors for ICH in patients with acute ischemic stroke undergoing successful ET. Methods: We performed a retrospective analysis of patients with large vessel occlusion in the anterior circulation who underwent successful ET at our university medical center between 2015 and 2018. ICH was diagnosed on non-enhanced CT and a binary outcome was defined: ICH occurrence in the immediate post-interventional phase within 12–36 h (yes/no). The impacts of clinical, radiological, and interventional parameters on outcome were assessed in logistic regression models. Results: One hundred and seven patients fulfilled the inclusion criteria. 37 (34.6%) showed an ICH of which 7 (6.5%) patients were diagnosed as symptomatic and 30 (28.04%) as asymptomatic. Multivariable regression analyses identified a lower ASPECTS (adjusted odds ratio (OR) 1.95, 95%CI: 1.4–3.63, P = 0.037), low collateral score (adjusted OR 0.12, 95%CI: 0.03–0.49, P = 0.003) and high Net Water Uptake (NWU) (adjusted OR 1.56, 95%CI: 2.34–1.03, P = 0.007) as independent predictors of ICH after successful ET. Conclusions: CT-based quantitative NWU, ASPECTS, and collateral score mediate tissue vulnerability and are reliable independent predictors of a bleeding event after successful ET. This imaging-based prediction model might be useful for early stratification of patients at high risk of a bleeding event after ET, especially with low ASPECTS.
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Affiliation(s)
- Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Radiology, University Hospital Münster, Münster, Germany
| | - André Kemmling
- Department of Radiology, University Hospital Münster, Münster, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- 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
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Kim JG, Lee D, Choi JC, Song Y, Lee DH, Suh DC. DWI-pc-ASPECT score in basilar artery occlusion: is 6 points or less always indicative of a bad outcome? Interv Neuroradiol 2019; 25:371-379. [PMID: 30803336 DOI: 10.1177/1591019919827505] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND PURPOSE The prognosis of patients with acute basilar arterial occlusion after endovascular reperfusion therapy with diffusion-weighted imaging - posterior circulation-Alberta Stroke Program Early Computed Tomography Score (DWI-pc-ASPECTS) of 6 or less remains unclear. We aimed to assess the characteristics and prognosis of endovascular reperfusion therapy in patients with acute basilar arterial occlusion and DWI-pc-ASPECTS of 6 or less. METHODS We analysed data collected from 1 January 2012 to 31 January 2018 in a prospective neuro-interventional registry of consecutive patients treated with endovascular reperfusion therapy. Clinical and imaging data on patients with DWI-pc-ASPECTS of 6 or less who underwent endovascular reperfusion therapy for acute basilar arterial occlusion were collected for this study. A good clinical outcome was defined as a modified Rankin scale of 2 or less at 90 days. RESULTS Forty-five acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less were included. Among them, 11 (24.4%) patients had a good clinical outcome at 90 days. Patients with a good clinical outcome had less severe neurological symptoms at presentation (National Institutes of Health Stroke Scale (NIHSS) 19.0 (12.0-25.0) vs. 8.0 (6.0-11.5); P = 0.003) and were younger (72.5 years (57.0-80.0 years) vs. 63.0 years (55.5-69.0 years), P = 0.096) than those with a poor clinical outcome. The symptomatic intracranial haemorrhage rate was significantly higher in the poor clinical outcome group (13 (38.2%)) than in the good clinical outcome group (0 (0.0%)) (P = 0.045). In particular, in patients aged over 70 years, a favourable outcome was low (18 (52.9%) vs. 1 (9.1%); P = 0.027) even after successful recanalisation. In a multivariate model, a low initial NIHSS score (odds ratio 1.21; 95% confidence interval 1.07-1.44; P = 0.0093) and age over 70 years (odds ratio 15.27; 95% confidence interval 1.85-379.79; P = 0.0321) were independent predictors of poor clinical outcome. CONCLUSIONS Even with DWI-pc-ASPECTS of 6 or less, good clinical outcome can be achieved after endovascular reperfusion therapy. Relatively mild initial symptoms and younger age can predict a better outcome in acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less.
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Affiliation(s)
- Joong-Goo Kim
- 1 Department of Neurology, Jeju National University, Jeju, Korea
| | - Dongwhane Lee
- 2 Department of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jay Chol Choi
- 1 Department of Neurology, Jeju National University, Jeju, Korea
| | - Yunsun Song
- 2 Department of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deok Hee Lee
- 2 Department of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae Chul Suh
- 2 Department of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Songsaeng D, Kaeowirun T, Sakarunchai I, Cheunsuchon P, Weankhanan J, Suwanbundit A, Krings T. Efficacy of Thrombus Density on Noninvasive Computed Tomography Neuroimaging for Predicting Thrombus Pathology and Patient Outcome after Mechanical Thrombectomy in Acute Ischemic Stroke. Asian J Neurosurg 2019; 14:795-800. [PMID: 31497104 PMCID: PMC6702996 DOI: 10.4103/ajns.ajns_238_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background and Purpose: The aim of this study was to investigate the efficacy of thrombus density on noninvasive computed tomography (CT) neuroimaging for predicting thrombus pathology and patient outcome after mechanical thrombectomy in acute ischemic stroke. Materials and Methods: This retrospective chart and imaging review included patients that were treated by mechanical thrombectomy at Siriraj Hospital according to the American Heart Association/American Stroke Association guidelines for the early management of patients with acute ischemic stroke from March 2010 to February 2015 study period. Preintervention noncontrast CT (NCCT), CT angiography (CTA), and/or contrast-enhanced CT (CECT) images were interpreted using CT densitometry. Pathology results were classified as white, red, or mixed thrombi. The result of treatment was evaluated by the modified Rankin Scale at 90 days after treatment. Results: From 97 included patients – 97 NCCT images, 48 CTA images, 48 CECT images, and 54 pathologic results of cerebral thrombi were included in the final analysis. Mean clot Hounsfield unit values on NCCT, CTA, and CECT were significantly different between red and white thrombus (P = 0.001 on NCCT, P = 0.03 on CTA, and P = 0.001 on CECT), and between red and mixed thrombus (P = 0.043 on NCCT and P = 0.002 on CTA). However, no significant difference was observed between white thrombus and mixed thrombus (P = 0.09 on NCCT, P = 1.00 on CTA, and P = 0.054 on CECT). There was no significant correlation between type of cerebral thrombus or clot density and the result of treatment. Conclusion: Thrombus density on CT was found to be a significant predictor of thrombus pathology; however, no significant association was observed between thrombus type or clot density and patient outcome after mechanical thrombectomy.
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Affiliation(s)
- Dittapong Songsaeng
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tharathorn Kaeowirun
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ittichai Sakarunchai
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Pornsuk Cheunsuchon
- Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jaruwan Weankhanan
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anek Suwanbundit
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Timo Krings
- Department of Medical Imaging, Division of Neuroradiology, Faculty of Medicine, University of Toronto, Canada
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Seon Jeong H, Kim J. Paradigm Shift for Thrombolysis for Patients with Acute Ischaemic Stroke, from Extension of the Time Window to the Rapid Recanalisation After Symptom Onset. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10313503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Intravenous thrombolysis (IVT) and intra-arterial thrombolysis (IAT) are useful therapeutic tools to improve functional outcomes after recanalisation of occluded vessels in patients with acute ischaemic stroke. IVT could be performed for more patients by extending the time interval to 4.5 hours from onset to IVT initiation; however, this does not significantly improve functional outcomes. Recent studies indicated that IAT, particularly intra-arterial thrombectomy (IA-thrombectomy), significantly improved functional outcomes after recanalisation of occluded vessels, particularly when the recanalisation was performed within 6 hours of symptom onset. The focus of thrombolysis for acute ischaemic stroke patients is changing from extending the time window for IVT to successfully achieving good functional outcomes with IA-thrombectomy, by performing it within the 6-hour time limit. In this review, we discuss the present status of and limitations of extending IA-thrombectomy for improved functional outcomes after thrombolysis.
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Affiliation(s)
- Hye Seon Jeong
- Department of Neurology and Daejeon-Chungnam Regional Cerebrovascular Center, Hospital and School of Medicine, Chungnam National University, Daejeon, South Korea
| | - Jei Kim
- Department of Neurology and Daejeon-Chungnam Regional Cerebrovascular Center, Hospital and School of Medicine, Chungnam National University, Daejeon, South Korea
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Shinoda N, Hori S, Mikami K, Bando T, Shimo D, Kuroyama T, Kuramoto Y, Matsumoto M, Hirai O, Ueno Y. Utility of relative ADC ratio in patient selection for endovascular revascularization of large vessel occlusion. J Neuroradiol 2017; 44:185-191. [DOI: 10.1016/j.neurad.2016.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 12/19/2016] [Accepted: 12/30/2016] [Indexed: 10/19/2022]
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Mokin M, Primiani CT, Ren Z, Kan P, Duckworth E, Turner RD, Turk AS, Fargen KM, Dabus G, Linfante I, Dumont TM, Brasiliense LBC, Shallwani H, Snyder KV, Siddiqui AH, Levy EI. Endovascular Treatment of Middle Cerebral Artery M2 Occlusion Strokes: Clinical and Procedural Predictors of Outcomes. Neurosurgery 2017; 81:795-802. [DOI: 10.1093/neuros/nyx060] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 01/23/2017] [Indexed: 11/14/2022] Open
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18
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Raoult H, Redjem H, Bourcier R, Gaultier-Lintia A, Daumas-Duport B, Ferré JC, Eugène F, Fahed R, Bartolini B, Piotin M, Desal H, Gauvrit JY, Blanc R. Mechanical thrombectomy with the ERIC retrieval device: initial experience. J Neurointerv Surg 2016; 9:574-577. [DOI: 10.1136/neurintsurg-2016-012379] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/20/2016] [Accepted: 04/29/2016] [Indexed: 11/03/2022]
Abstract
ObjectiveTo report our experience with the Embolus Retriever with Interlinked Cage (ERIC) stentriever for use in mechanical endovascular thrombectomy (MET).MethodsThirty-four consecutive patients with acute stroke (21 men and 13 women; median age 66 years) determined appropriate for MET were treated with ERIC and prospectively included over a 6-month period at three different centers. The ERIC device differs from typical stentrievers in that it is designed with a series of interlinked adjustable nitinol cages that allow for fast thrombus capture, integration, and withdrawal. The evaluated endpoints were successful revascularization (Thrombolysis in Cerebral Infarction (TICI) 2b–3) and good clinical outcomes at 3 months (modified Rankin Scale (mRS) 0–2).ResultsLocations of the occlusions included the middle cerebral artery (13 patients), terminal carotid artery (11 patients), basilar artery (1 patient), and tandem occlusions (9 patients). IV thrombolysis was performed in 20/34 (58.8%) patients. Median times from symptom onset to recanalization and from puncture to recanalization were 325.5 min (180–557) and 78.5 min (14–183), respectively. Used as the first-line device, ERIC achieved a successful recanalization in 20/24 (83.3%) patients. Successful recanalization was associated with lower National Institutes of Health Stroke Scale scores at 24 h (8±6.5 vs 21.5±2.1; p=0.008) and lower mRS at 3 months (2.7±2.1 vs 5.3±1.1; p=0.04). Three procedural complications and four asymptomatic hemorrhages were recorded. Good clinical outcomes at 3 months were seen in 15/31 (48.4%) patients.ConclusionsThe ERIC device is an innovative stentriever allowing fast, effective, and safe MET.
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Gory B, Eldesouky I, Sivan-Hoffmann R, Rabilloud M, Ong E, Riva R, Gherasim DN, Turjman A, Nighoghossian N, Turjman F. Outcomes of stent retriever thrombectomy in basilar artery occlusion: an observational study and systematic review. J Neurol Neurosurg Psychiatry 2016; 87:520-5. [PMID: 25986363 DOI: 10.1136/jnnp-2014-310250] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 04/08/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Basilar artery occlusion (BAO) remains one of the most devastating subtypes of stroke with high mortality and poor outcome. Early recanalisation is the most powerful predictor of favourable outcome in patients with stroke, and may be improved with mechanical thrombectomy using stent retriever devices. However, the benefit in functional outcome and safety of stent retrievers are not yet well known. The aim of this study was to assess efficacy and safety profiles of stent retriever thrombectomy in BAO patients with stroke. METHODS We analysed data retrospectively from our consecutive clinical series and conducted a systematic review and meta-analysis of all previous studies of stent retriever thrombectomy in BAO patients with stroke between November 2010 and April 2014. RESULTS From March 2010 to March 2013, 22 patients with acute BAO were treated with a Solitaire stent retriever in our series. Favourable outcome was significantly associated with younger age and distal BAO. The literature search identified 15 previous studies involving a total of 312 subjects. In the meta-analysis, including our series data, the recanalisation rate (Thrombolysis In Cerebral Infarction (TICI) score ≥ 2b) reached 81% (95% CI 73% to 87%). The rate of symptomatic intracranial haemorrhage was 4% (95% CI 2% to 8%), favourable outcome (modified Rankin Scale (mRS) ≤ 2 at 3 months) was found in 42% (95% CI 36% to 48%) and mortality rate was 30% (95% CI 25% to 36%). CONCLUSIONS Stent retriever thrombectomy is a safe treatment modality for patients with stroke presenting with BAO. Although the stent retrievers showed a good recanalisation rate, there are currently no randomised clinical trials to assess its clinical efficacy in comparison with the reference treatment.
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Affiliation(s)
- Benjamin Gory
- Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Islam Eldesouky
- Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Rotem Sivan-Hoffmann
- Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Murielle Rabilloud
- Department of Biostatitics, UMR 5558, Hospices Civils de Lyon, Lyon, France
| | - Elodie Ong
- Department of Neurology, Stroke Unit, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Roberto Riva
- Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Dorin Nicolae Gherasim
- Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Alexis Turjman
- Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Norbert Nighoghossian
- Department of Neurology, Stroke Unit, Hôpital Neurologique Pierre Wertheimer, Bron, France
| | - Francis Turjman
- Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Bron, France
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21
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Jiang S, Fei A, Peng Y, Zhang J, Lu YR, Wang HR, Chen M, Pan S. Predictors of Outcome and Hemorrhage in Patients Undergoing Endovascular Therapy with Solitaire Stent for Acute Ischemic Stroke. PLoS One 2015; 10:e0144452. [PMID: 26642052 PMCID: PMC4671621 DOI: 10.1371/journal.pone.0144452] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/18/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endovascular mechanical thrombectomy is emerging as a promising therapeutic approach for acute ischemic stroke and show some advantages. However, the data of predicting clinical outcome after thrombectomy with Solitaire retriever were limited. We attempt to identify prognostic factors of clinical outcome in patients with acute ischemic stroke undergoing thrombectomy with Solitaire retriever. METHODS We conducted a retrospective analysis of consecutive acute ischemic strokes cases treated between December 2010 and December2013 where the Solitaire stent retriever was used for acute ischemic stroke. We assessed the effect of selected demographic characteristics, clinical factors on poor outcome at 3 months (modified Rankin score 3-6), mortality at 3 months, and hemorrhage within 24 h (symptomatic and asymptomatic). Clinical, imaging and logistic variables were analyzed. A multivariate logistic regression analysis was used to identify variables influencing clinical outcome, based on discharge NIHSS score change and mRS at 3 months. RESULTS Eighty nine consecutive patients with acute ischemic stroke underwent mechanical thrombectomy. Multivariate analysis revealed that admission NIHSS score, Serum glucose and endovascular procedure duration were independently associated with clinical outcome. Sex, NIHSS score at admission, diabetes and time of operation were associated with sICH in 1 day. NIHSS score ≥20 (OR 9.38; 95% CI 2.41-36.50), onset to reperfusion >5 hours (OR 5.23; 95% CI1.34,20.41) and symptomatic intracranial hemorrhage (OR 10.19; 95% CI1.80,57.83) were potential predictive factors of mortality at 3 months. CONCLUSION Multiple pre- and intra-procedural factors can be used to predict clinical outcome, symptomatic intracranial hemorrhage and mortality in acute ischemic stroke patients undergoing endovascular therapy. This knowledge is helpful for patients selection for endovascular mechanical thrombectomy.
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Affiliation(s)
- Shaowei Jiang
- Emergency Department, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Aihua Fei
- Emergency Department, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Ya Peng
- Cerebral Vascular Disease Center, The First People’s Hospital of Changzhou, Soochow University, Changzhou, 213003, China
| | - Jun Zhang
- Department of Medical Imaging, The First People’s Hospital of Changzhou, Soochow University, Changzhou, 213003, China
| | - You-ran Lu
- Department of Medical Imaging, The First People’s Hospital of Changzhou, Soochow University, Changzhou, 213003, China
| | - Hai-rong Wang
- Emergency Department, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Miao Chen
- Emergency Department, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Shuming Pan
- Emergency Department, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
- * E-mail:
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Phan K, Phan S, Huo YR, Jia F, Mortimer A. Outcomes of endovascular treatment of basilar artery occlusion in the stent retriever era: a systematic review and meta-analysis. J Neurointerv Surg 2015; 8:1107-1115. [DOI: 10.1136/neurintsurg-2015-012089] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/30/2015] [Indexed: 11/03/2022]
Abstract
BackgroundStent retriever thrombectomy has recently been found to be effective for anterior circulation strokes, but its efficacy for basilar artery occlusion (BAO) is unclear.ObjectiveTo carry out a systematic review and meta-analysis to analyze the available evidence for the use of stent retrievers for BAO.MethodsTwo independent reviewers searched six databases for studies reporting outcomes following endovascular treatment for BAO.ResultsA total of 17 articles (6 prospective and 11 retrospective) were included. The weighted mean age of patients was 67 years (range 59–82) and 59% were male. Thrombolytic drugs were administered intravenously and intra-arterially in 46% (range 0–88%) and 38% (range 0–90%) of patients, respectively. Weighted pooled estimates of successful recanalization (TICI 2b–3) and good outcome (modified Rankin Scale ≤2) were 80.0% (95% CI 70.7% to 88.0%; I2=80.28%; p<0.001) and 42.8% (95% CI 34.0% to 51.8%; I2=61.83%; p=0.002), respectively. Pooled mortality was 29.4% (95% CI 23.9% to 35.3%; I2=37.01%; p=0.087). Incidence of procedure-related complications and symptomatic hemorrhage was 10.0% (95% CI 3.7% to 18.3%; I2=61.05%; p=0.017) and 6.8% (95% CI 3.5% to 10.8%; I2=37.99%; p=0.08), respectively.ConclusionsStent retriever thrombectomy achieves a high rate of recanalization and functional independence while being relatively safe for patients with BAO. Future prospective studies with long-term follow-up are warranted.
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Park JH, Han YM, Jang KS, Yoon WS, Jang DK, Park SK. Angiographic and Clinical Factors Related with Good Functional Outcome after Mechanical Thrombectomy in Acute Cerebral Artery Occlusion. J Korean Neurosurg Soc 2015; 58:192-6. [PMID: 26539260 PMCID: PMC4630348 DOI: 10.3340/jkns.2015.58.3.192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 07/17/2015] [Accepted: 08/04/2015] [Indexed: 01/19/2023] Open
Abstract
Objective The aim of this study is to investigate good prognostic factors for an acute occlusion of a major cerebral artery using mechanical thrombectomy. Methods Between January 2013 to December 2014, 37 consecutive patients with acute occlusion of a major cerebral artery treated by mechanical thrombectomy with stent retrievers were conducted. We analyzed clinical and angiographic factors retrospectively. The collateral flow and the result of recanalization were sorted by grading systems. Outcome was assessed by National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 90 days. We compared the various parameters between good and poor angiographic and clinical results. Results Twenty seven patients demonstrated good recanalization [Thrombolysis in Cerebral Infarction (TICI) 2b or 3] after thrombectomy. At the 90-day follow up, 19 patients had good (mRS, 0-2), 14 had moderate (3-4) and four had poor outcomes (5-6). The mRS of older patients (≥75 years) were poor than younger patients. Early recanalization, high Thrombolysis in Myocardial Infarction risk score, and low baseline NIHSS were closely related to 90-day mRS, whereas high TICI was related to both mRS and the decrease in the NIHSS. Conclusion NIHSS decreased markedly only when recanalization was successful. A good mRS was related to low initial NIHSS, good collateral, and early successful recanalization.
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Affiliation(s)
- Jong Hyuk Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Min Han
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyeong Sool Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wan Soo Yoon
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Kyu Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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To CY, Rajamand S, Mehra R, Falatko S, Badr Y, Richards B, Qahwash O, Fessler RD. Outcome of mechanical thrombectomy in the very elderly for the treatment of acute ischemic stroke: the real world experience. Acta Radiol Open 2015; 4:2058460115599423. [PMID: 26445678 PMCID: PMC4580118 DOI: 10.1177/2058460115599423] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 07/15/2015] [Indexed: 01/19/2023] Open
Abstract
Background Although initial studies of neuroendovascular intervention did not review benefit over intravenous thrombolytics (iv r-tPA), recent studies have suggested otherwise. Elderly patients (age ≥80 years) are typically excluded from clinical trials. Purpose To examine the utility of mechanical thrombectomy based on patient outcomes. Material and Methods All stroke-alert activations at our health system from January 2011 to June 2014 were examined. All patients aged ≥80 years who had undergone mechanical thrombectomy were identified. Clinical characteristics included physiologic imaging findings, use of intravenous thrombolytics, baseline and postoperative National Institute of Health Stroke Scale (NIHSS), thrombolysis in cerebral infarction scores (TICI), and discharge destination. Results Mean NIHSS on presentation was 18.2 (range, 6–31), and 13.3 (range, 3–30) post thrombectomy. Three (16.6%) patients received iv r-tPA, two (11.1%) had symptomatic intracranial hemorrhage. Eight (44.4%) died, eight (44.4%) were discharged to nursing homes, and two (11.7%) were discharged to inpatient rehab and subsequently home. Favorable outcome was achieved in five (27.7%) patients. Fourteen (77.7%) patients had physiologic imaging prior to intervention. Three (75%) of four patients who did not have physiologic imaging prior to thrombectomy died. Thirteen (66.6%) patients had TICI 3 recanalization. Conclusion Our study showed that although there remains a role of mechanical thrombectomy in the treatment of acute ischemic stroke in very elderly patients, it is associated with significant higher morbidity and mortality compared to younger patients, but should remain a very viable treatment option when quality of life is the most important consideration.
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Affiliation(s)
- Chiu Yuen To
- Providence Hospital and Medical Center, Southfield, MI, USA
| | - Sina Rajamand
- Providence Hospital and Medical Center, Southfield, MI, USA
| | - Ratnesh Mehra
- Providence Hospital and Medical Center, Southfield, MI, USA
| | | | - Yaser Badr
- Badr Medical Corperation, Los Angeles, CA, USA
| | - Boyd Richards
- Providence Hospital and Medical Center, Southfield, MI, USA
| | - Omar Qahwash
- St. John Hospital and Medical Center, Detroit, MI, USA
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Puñal-Riobóo J, Atienza G, Blanco M. Safety and Efficacy of Mechanical Thrombectomy Using Stent Retrievers in the Endovascular Treatment of Acute Ischaemic Stroke: A Systematic Review. INTERVENTIONAL NEUROLOGY 2015; 3:149-64. [PMID: 26279662 DOI: 10.1159/000430474] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The treatment of choice for acute ischaemic stroke is the intravenous administration of recombinant tissue plasminogen activator within 3-4.5 h of symptom onset. However, the use of a thrombolytic would be limited by its narrow therapeutic window and contraindications. As a result, in recent years, techniques such as mechanical thrombectomy have emerged, which employ thrombus retrieval devices, such as stent retrievers (Solitaire™, Trevo® or Revive™), whose safety and efficacy in the endovascular treatment of acute ischaemic stroke is analysed in this article. METHODS A systematic literature search was undertaken until March 2015. The quality of evidence was assessed according to the GRADE methodology. A meta-analysis of the results of randomised controlled trials (RCTs) was performed, and the weighted average for the case series' sample size was calculated (Review Manager v5.2 and SPSS v19). RESULTS Seventeen primary studies (2 RCTs, Solitaire™ and Trevo® vs. Merci®, and 15 case series) were selected. The RCT results show that stent retrievers have a safety profile similar to the Merci® device. However, both Solitaire™ and Trevo® achieved a higher recanalisation success rate (OR, 4.56; 95% CI, 2.63-7.90; p < 0.00001) and appropriate clinical outcome at 90 days (OR, 2.54; 95% CI, 1.52-4.25; p < 0.0004), although the 90-day mortality rate was similar in both groups (OR, 0.75; 95% CI, 0.17-3.37; p = 0.70). CONCLUSIONS Stent retrievers appear to be safe and effective devices, achieving high recanalisation rates and good clinical outcomes in the endovascular treatment of patients with acute ischaemic stroke due to the occlusion of intracranial arteries in comparison with the clot retriever Merci®.
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Affiliation(s)
- Janet Puñal-Riobóo
- Galician Department of Health, Galician Agency for Health Technology Assessment (avalia-t), Santiago de Compostela, Spain
| | - Gerardo Atienza
- Galician Department of Health, Galician Agency for Health Technology Assessment (avalia-t), Santiago de Compostela, Spain
| | - Miguel Blanco
- Neurovascular Area, Neurology Department, Clinic University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
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Eugène F, Gauvrit JY, Ferré JC, Gentric JC, Besseghir A, Ronzière T, Raoult H. One-year MR angiographic and clinical follow-up after intracranial mechanical thrombectomy using a stent retriever device. AJNR Am J Neuroradiol 2014; 36:126-32. [PMID: 25125665 DOI: 10.3174/ajnr.a4071] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Little is known about the consequences of arterial wall damage that may be due to mechanical endovascular thrombectomy. Our aim was to perform 1-year MR angiographic and clinical follow-up of patients treated with mechanical endovascular thrombectomy using the Solitaire device. MATERIALS AND METHODS Patients with stroke treated between August 2010 and July 2012 were prospectively evaluated with a minimum follow-up of 1 year after mechanical endovascular thrombectomy. Angiographic follow-up was performed on a 3T MR imaging scanner and included intracranial artery TOF MRA and supra-aortic artery gadolinium-enhanced MRA. Images were assessed to detect arterial abnormalities (stenosis, occlusion, dilation) and were compared with the final post-mechanical endovascular thrombectomy run to differentiate delayed and pre-existing abnormalities. Clinical evaluation was performed with the mRS and the 36-Item Short-Form Health Survey questionnaire quality-of-life scale. RESULTS Thirty-nine patients were angiographically assessed at the mean term of 19 ± 4 months. MRA showed intracranial artery abnormalities in 10 patients, including 5 delayed intracranial artery abnormalities in 4 patients (4 stenoses and 1 dilation), 4 cases of pre-existing intracranial artery stenosis, and 2 occlusions. Pre-existing etiologic cervical artery stenosis or occlusion was observed in 2 patients. All these patients remained asymptomatic during the follow-up period. A significant clinical improvement was observed at 1-year follow-up in comparison with 3-month follow-up (P < .0001), with a good outcome achieved in 62.5% of patients and an acceptable quality of life restored. CONCLUSIONS One-year follow-up identifies delayed asymptomatic arterial abnormalities in patients treated with the Solitaire device.
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Affiliation(s)
- F Eugène
- From the Departments of Neuroradiology (F.E., J.-Y.G., J.-C.F., H.R.)
| | - J-Y Gauvrit
- From the Departments of Neuroradiology (F.E., J.-Y.G., J.-C.F., H.R.)
| | - J-C Ferré
- From the Departments of Neuroradiology (F.E., J.-Y.G., J.-C.F., H.R.)
| | - J-C Gentric
- Department of Neuroradiology (J.-C.G.), Centre Hospitalier Universitaire, Brest, France
| | | | - T Ronzière
- Neurology (T.R.), Centre Hospitalier Universitaire, Rennes, France
| | - H Raoult
- From the Departments of Neuroradiology (F.E., J.-Y.G., J.-C.F., H.R.)
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Future directions for endovascular management of patients with acute ischemic stroke. J Neuroradiol 2014; 41:151-2. [DOI: 10.1016/j.neurad.2014.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Recanalization and mortality rates of thrombectomy with stent-retrievers in octogenarian patients with acute ischemic stroke. Cardiovasc Intervent Radiol 2014; 38:288-94. [PMID: 24923241 DOI: 10.1007/s00270-014-0920-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 04/21/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Our objective was to evaluate the effect of treatment with stent-retrievers in octogenarians suffering an acute ischemic stroke. METHODS A total of 150 consecutive patients with acute stroke who were treated with stent-retrievers between April 2010 and June 2012 were retrospectively reviewed. Patients were divided into those <80 years old (n = 116) and those ≥80 (n = 34). Baseline characteristics, procedure data, and endpoints (postprocedural NIHSS, death, and mRS at 3 months) were compared. RESULTS High blood pressure, atrial fibrillation, and anticoagulation were more frequent in octogenarians (p = 0.01, 0.003, and 0.04 respectively). There were no differences between both groups regarding previous intravenous thrombolysis (32.4 vs. 48.3 %, p = 0.1), preprocedural NIHSS (18.1 vs. 16.8, p = 0.3), procedure time (74.5 (40-114) min vs. 63 (38-92) min, p = 0.2), revascularization time (380.5 (298-526.3) min vs. 350 (296.3-452.8), p = 0.3), TICI ≥ 2B (88.2 vs. 93.9 %, p = 0.1), and symptomatic haemorrhage (5.9 vs. 2.6 %, p = 0.3). Discharge NIHSS was higher in octogenarians (9.7 vs. 6.5, p = 0.03). Death and 3-month mRS ≥3 were more frequent in octogenarians (35.3 vs. 17.2 %, p = 0.02 and 73.5 vs. 37.1 %, p = 0.02). ICA-involvement and prolonged revascularization involved higher mortality (66.7 vs. 27.6 %, p = 0.03) and worse mRS (50 vs. 24.4 %, p = 0.06) in octogenarians. CONCLUSIONS In our series, treatment with stent-retrievers in octogenarians with acute ischemic stroke achieved good rates of recanalization but with a high mortality rate. ICA involvement and revascularization times beyond 6 hours associated to a worse prognosis. These data might be of value in the design of prospective studies evaluating the clinical efficacy of the endovascular treatments in octogenarians.
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Vanicek J, Bulik M, Brichta J, Jancalek R. Utility of a rescue endovascular therapy for the treatment of major strokes refractory to full-dose intravenous thrombolysis. Br J Radiol 2014; 87:20130545. [PMID: 24641217 DOI: 10.1259/bjr.20130545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Large artery occlusion (LAO) in patients with major stroke predicts poor revascularization by intravenous thrombolysis (IVT) and more likely results in a poor outcome. We focused on the effects of intra-arterial thrombolysis (IAT) and endovascular mechanical recanalization (EMR) as rescue therapies in major strokes refractory to IVT. METHODS A retrospective analysis of 87 patients (National Institutes of Health Stroke Scale >20), who did not respond to full-dose IVT due to LAO, was performed based on their endovascular therapy status. IAT was performed as an intraclot infusion of alteplase, and EMR was provided by the Solitaire device™ (Covidien, Dubin, Ireland). The recanalization and 3-month outcome rates after IAT/EMR were correlated with a group of patients who were scheduled to receive endovascular treatment but who underwent only IVT. RESULTS We achieved successful recanalization by IAT and EMR in 68.7% and 76.1% of patients, respectively. Despite no significant differences in mortality between IAT and EMR, a trend towards better outcomes after IAT and a statistically significant increase for outcome-modified Rankin scale (mRS) 0-3 (45.7%) and mRS 0-2 (34.9%) after EMR was noted when compared with IVT. The degree of recanalization did not correlate with the functional results except for the good-moderate outcome after successful recanalization by EMR. CONCLUSION EMR by the Solitaire device is a safe and beneficial method for the rescue treatment of patients with major stroke whose neurological status does not improve and who fail to recanalize the LAO after a 1-h full dose of IVT. ADVANCES IN KNOWLEDGE The article verifies efficiency of the Solitaire device in major strokes.
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Affiliation(s)
- J Vanicek
- Department of Diagnostic Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Soize S, Naggara O, Desal H, Costalat V, Ricolfi F, Pierot L. Endovascular treatment of acute ischemic stroke in France: A nationwide survey. J Neuroradiol 2014; 41:71-9. [DOI: 10.1016/j.neurad.2013.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 12/19/2013] [Accepted: 12/27/2013] [Indexed: 01/19/2023]
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Simons N, Mitchell P, Dowling R, Gonzales M, Yan B. Thrombus composition in acute ischemic stroke: a histopathological study of thrombus extracted by endovascular retrieval. J Neuroradiol 2014; 42:86-92. [PMID: 24560545 DOI: 10.1016/j.neurad.2014.01.124] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 01/20/2014] [Accepted: 01/23/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE The composition of occlusive thrombus in acute ischemic stroke may affect treatment success. Neuroimaging characteristics may correlate with thrombus composition. In this study we aimed to investigate the relationship between the hyperdense artery sign (HAS) on imaging and thrombus composition. MATERIALS AND METHODS Acute ischemic stroke patients who underwent endovascular thrombus retrieval from 2010-2012 were prospectively recruited. One blinded pathologist prepared the histology sections of retrieved thrombi whereby staining with haematoxylin and eosin and CD34 immunostain were performed. Histology sections were categorised into 4 phases of thrombus formation: red blood cell (RBC) dominant, RBC proportion equal to fibrin, fibrin dominant and organised fibrin. Computed tomography (CT) brain scans were assessed for HAS. Fisher's exact test was performed to identify an association between HAS and thrombus composition. RESULTS Forty patients were included. The mean age was 65.6±12.9 years and 67.5% were male. Atrial fibrillation was detected in 19 (47.5%) patients, diabetes mellitus in 6 (15.0%), hypercholesterolaemia in 11 (27.5%), hypertension in 20 (50.0%) and previous stroke or transient ischemic attack in 8 (20.0%) patients. Of the retrieved thrombi, 11 (27.5%) were RBC dominant, 11 (27.5%) RBC proportion was equal to fibrin, 7 (17.5%) fibrin dominant and 11 (27.5%) organised fibrin pathology. HAS was present in 29 (72.5%) patients and was significantly associated with thrombus early phase pathology (P<0.05). CONCLUSION HAS was significantly associated with early phase thrombus composition. This may enable the prediction of thrombus composition and allow for targeted selection of therapeutic modality.
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Affiliation(s)
- Natasha Simons
- Melbourne Brain Centre, Level 4, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Peter Mitchell
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Richard Dowling
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Michael Gonzales
- Department of Histopathology, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Bernard Yan
- Melbourne Brain Centre, Level 4, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia; Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia.
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Lefevre PH, Lainay C, Thouant P, Chavent A, Kazemi A, Ricolfi F. Solitaire FR as a first-line device in acute intracerebral occlusion: a single-centre retrospective analysis. J Neuroradiol 2013; 41:80-6. [PMID: 24388566 DOI: 10.1016/j.neurad.2013.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 10/05/2013] [Accepted: 10/22/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Analysing the clinical and angiographical effectiveness of the Solitaire FR as a mechanical thrombectomy device in acute intracerebral occlusion. METHODS Sixty-two patients were retrospectively included between January 2010 and March 2012. All of them underwent mechanical thrombectomy with the Solitaire FR device with or without intravenous thrombolysis. Twenty-five patients had an occlusion of the basilar artery, 1 had a posterior cerebral artery occlusion. There were 16 M1 middle cerebral artery occlusions, 9 carotid T occlusions and 11 tandem occlusions. Clinical status was evaluated using the National Institute of Health Stroke Scale (NIHSS) before and 24 hours after treatment and at discharge. The Modified Rankin Scale (mRS) was evaluated at 3 months. RESULTS Mean age of patients was 64.8 years. Mean NIHSS score on admission was 19.8. Stand-alone thrombectomy was used in 47 patients (75.8%). Recanalization was successful (TICI score 2b or 3) in 23 of 26 (88.5%) patients with posterior circulation occlusion and in 23 of 36 (63.9%) patients with anterior circulation occlusion. NIHSS improved by more than 10 points for 15 of 59 patients with initial NIHSS over 10. MRS was 0-2 in 25 of 62 patients (40.3%). Overall, 23 patients out of 62 died (37%). No complications related to the Solitaire device occurred. CONCLUSION These results confirm that the Solitaire FR device is safe and effective in stand-alone thrombectomy.
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Affiliation(s)
- Pierre-Henri Lefevre
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - Claire Lainay
- Service de neurologie, CHU de Dijon, hôpital Général, 3, rue du Faubourg-Raines, 21000 Dijon, France
| | - Pierre Thouant
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - Adrien Chavent
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - Apolline Kazemi
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - Frédéric Ricolfi
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France
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Mortimer AM, Bradley MD, Renowden SA. Endovascular therapy in hyperacute ischaemic stroke: history and current status. Interv Neuroradiol 2013; 19:506-18. [PMID: 24355158 DOI: 10.1177/159101991301900417] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 09/15/2013] [Indexed: 01/19/2023] Open
Abstract
This is a literature review on to the use of endovascular therapy in hyperacute ischaemic stroke secondary to large vessel occlusion (LVO). The prognosis for LVO is generally poor and the efficacy of intravenous tissue plasminogen activator (IV TPA) in the treatment of this subtype of stroke is questionable. It is well documented that recanalisation is associated with improved outcomes but IV TPA has limited efficacy in LVO recanalisation and the complication rates are higher for IV TPA in this stroke subset. Improved recanalisation rates have been demonstrated with intra-arterial TPA and first and second generation mechanical techniques but the rate of favourable outcome has not overtly mirrored this improvement. Several controversial trials using these early techniques have recently been published but fail to reflect modern practice which centres on the use of stent-retriever technology. This has been proven to be superior to older techniques. Not only are recanalisation rates higher, but the speed of recanalisation is greater and clinical results are improved. Multiple observational studies demonstrate consistently high rates of LVO recanalisation; TICI 2b/3 in the order of 65-95% and, rates of favourable outcome (mRS 0-2) in the order of 55% (42.5-77%) in clinically moderate to severe stroke with complicating symptomatic haemorrhage in the order of 1.5-15%. A major factor determining outcome is time to treatment but success has been demonstrated using these devices with bridging therapy, after IV TPA failure or as a stand-alone treatment.
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Affiliation(s)
- Alex M Mortimer
- Department of Neuroradiology, Frenchay Hospital; Bristol, United Kingdom -
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Lee WI, Mitchell P, Dowling R, Yan B. Clinical factors are significant predictors of outcome post intra-arterial therapy for acute ischaemic stroke: a review. J Neuroradiol 2013; 40:315-25. [PMID: 24239412 DOI: 10.1016/j.neurad.2013.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 08/16/2013] [Accepted: 09/17/2013] [Indexed: 11/28/2022]
Abstract
Intra-arterial therapy (IAT) provides superior recanalisation rates, approaching 80% for the current generation of endovascular devices. Furthermore, IAT may allow for an extended therapeutic window beyond that which is permissible for intravenous thrombolysis. However, the improved recanalisation rates are not matched by concordant clinical outcomes, leading to an invigorated search for predictors of clinical outcome. There is emerging evidence that younger age, mild-moderate stroke, and shorter vessel occlusion time are associated with better clinical outcome after IAT. This review aims to critically appraise current evidence that may inform changes in the selective inclusion of clinical factors in the future design and trial of IAT.
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Affiliation(s)
- Wei-I Lee
- Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia
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Soize S, Kadziolka K, Estrade L, Serre I, Barbe C, Pierot L. Outcome after mechanical thrombectomy using a stent retriever under conscious sedation: comparison between tandem and single occlusion of the anterior circulation. J Neuroradiol 2013; 41:136-42. [PMID: 23906737 DOI: 10.1016/j.neurad.2013.07.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 06/14/2013] [Accepted: 07/02/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE In acute ischemic stroke patients, internal carotid artery/middle cerebral artery (ICA/MCA) occlusion in tandem predicts a poor outcome after systemic thrombolysis. This study aimed to compare outcomes after mechanical thrombectomy for tandem and single occlusions of the anterior circulation. MATERIALS AND METHODS This prospective study included consecutive patients with acute ischemic stroke of the anterior circulation who had undergone mechanical thrombectomy performed with a stent retriever under conscious sedation within 6h of symptom onset. Data on clinical, imaging and endovascular findings were collected. In cases of tandem occlusion, distal thrombectomy (retrograde approach) was performed first whenever possible. Tandem and single occlusions were compared in terms of functional outcome and mortality at 3 months. RESULTS From May 2010 to April 2012, 42 patients with acute ischemic stroke attributable to MCA and/or ICA occlusion were treated. Eleven patients (26.2%) presented with tandem occlusions and 31 patients (73.8%) had a single anterior circulation occlusion. Baseline characteristics were similar between the two groups. Recanalization status also did not differ significantly (P=0.76), but patients with tandem occlusions had poorer functional outcomes (18.2% vs. 67.7% for single occlusions; P=0.01), a higher mortality rate at 3 months (45.5% vs. 12.9%, respectively; P=0.03) and more symptomatic intracranial hemorrhages at 24h (9.7% vs. 0%, respectively; P=0.01). A high rate of early proximal re-occlusion or severe residual stenosis (66%) was also observed in the tandem group. CONCLUSION Tandem occlusions had poor clinical outcomes after mechanical thrombectomy compared with single occlusions. The retrograde approach (treatment of distal occlusion first) used in patients under conscious sedation may have contributed to these poor outcomes.
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Affiliation(s)
- Sébastien Soize
- Service de radiologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France
| | - Krzysztof Kadziolka
- Service de radiologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France
| | - Laurent Estrade
- Service de radiologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France
| | - Isabelle Serre
- Service de neurologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France
| | - Coralie Barbe
- Unité d'aide méthodologique, pôle recherche et innovations, université de Reims, hôpital Robert-Debré, rue du Généra-Koening, 51100 Reims, France
| | - Laurent Pierot
- Service de radiologie, université de Reims, hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims, France.
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