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Salerno A, Michel P, Strambo D. Revascularization of arterial occlusions in posterior circulation acute ischemic stroke. Curr Opin Neurol 2024; 37:26-31. [PMID: 38085602 DOI: 10.1097/wco.0000000000001234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW This review highlights the latest advancements achieved in the revascularization of arterial occlusions associated with an acute ischemic stroke affecting the posterior circulation. It delves into the frequency and outcomes based on specific arterial segments and presents current evidence supporting revascularization treatments, including intravenous thrombolysis and endovascular thrombectomy. RECENT FINDINGS Comprehensive evidence for treatment across major arterial segments of the posterior circulation -- vertebral artery, basilar artery, posterior cerebral artery, cerebellar arteries, and multilevel posterior occlusions -- is provided. Additionally, the latest findings from randomized clinical trials on basilar artery occlusion are explored alongside results from extensive retrospective analyses of isolated vertebral and posterior cerebral artery occlusions. SUMMARY Current research supports the treatment decision in acute ischemic strokes of the posterior circulation using both intravenous thrombolysis and endovascular thrombectomy. This review also emphasizes existing knowledge gaps in the management of these strokes and advocates for more randomized clinical trials, notably concerning the posterior cerebral artery (currently ongoing), isolated vertebral artery, and multilevel posterior circulation occlusions.
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Affiliation(s)
- Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Sirimarco G, Strambo D, Nannoni S, Labreuche J, Cereda C, Dunet V, Puccinelli F, Saliou G, Meuli R, Eskandari A, Wintermark M, Michel P. Predicting Penumbra Salvage and Infarct Growth in Acute Ischemic Stroke: A Multifactor Survival Game. J Clin Med 2023; 12:4561. [PMID: 37510676 PMCID: PMC10380847 DOI: 10.3390/jcm12144561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Effective treatment of acute ischemic stroke requires reperfusion of salvageable tissue. We investigated the predictors of penumbra salvage (PS) and infarct growth (IG) in a large cohort of stroke patients. METHODS In the ASTRAL registry from 2003 to 2016, we selected middle cerebral artery strokes <24 h with a high-quality CT angiography and CT perfusion. PS and IG were correlated in multivariate analyses with clinical, biochemical and radiological variables, and with clinical outcomes. RESULTS Among 4090 patients, 551 were included in the study, 50.8% male, mean age (±SD) 66.3 ± 14.7 years, mean admission NIHSS (±SD 13.3 ± 7.1) and median onset-to-imaging-time (IQR) 170 (102 to 385) minutes. Increased PS was associated with the following: higher BMI and lower WBC; neglect; larger penumbra; absence of early ischemic changes, leukoaraiosis and other territory involvement; and higher clot burden score. Reduced IG was associated with the following: non-smokers; lower glycemia; larger infarct core; absence of early ischemic changes, chronic vascular brain lesions, other territory involvement, extracranial arterial pathology and hyperdense middle cerebral artery sign; and higher clot burden score. When adding subacute variables, recanalization was associated with increased PS and reduced IG, and the absence of haemorrhage with reduced IG. Collateral status was not significantly associated with IG nor with PS. Increased PS and reduced IG correlated with better 3- and 12-month outcomes. CONCLUSION In our comprehensive analysis, multiple factors were found to be responsible for PS or IG, the strongest being radiological features. These findings may help to better select patients, particularly for more aggressive or late acute stroke treatment.
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Affiliation(s)
- Gaia Sirimarco
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
- Neurology Unit, Department of Internal Medicine, Riviera Chablais Hospital, 1847 Rennaz, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Julien Labreuche
- Statistical Unit, Regional House of Clinical Research, University of Lille, CHU Lille, EA 2694-Santé Publique: Épidémiologie et Qualité des Soins, 59000 Lille, France
| | - Carlo Cereda
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
- Stroke Center, Neurology Service, Ospedale Civico di Lugano, 6900 Lugano, Switzerland
| | - Vincent Dunet
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Francesco Puccinelli
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Guillaume Saliou
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Reto Meuli
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Ashraf Eskandari
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Max Wintermark
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
- Department of Diagnostic and Interventional Radiology, Neuroradiology Division, Stanford University and Medical Center, Stanford, CA 94305, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
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Li X, Guo D, Zhou W, Hu Y, Zhou H, Chen Y. Oxidative Stress and Inflammation Markers Associated with Multiple Peripheral Artery Occlusions in Elderly Patients. Angiology 2022; 74:472-487. [PMID: 35786005 DOI: 10.1177/00033197221111860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Pro-oxidative stress and pro-inflammatory responses can influence each other in the development of atherosclerosis. This study evaluated the relationship between oxidative stress, inflammation, and multiple peripheral artery occlusions in elderly patients (age mean 71.2 ± 8.1 years). Methods: A total of 723 participants were enrolled: 67 healthy subjects, 214 patients with common iliac artery occlusions, 224 patients with popliteal artery occlusions, and 218 patients with femoral artery occlusions. We measured oxidative stress biomarkers (malondialdehyde [MDA], F2-isoprostane [F2-isoP], total oxidant status [TOS], and ischemia-modified albumin [IMA]) and the expressions of molecules in mimecan (MIME)/nuclear factor kappa B (NF-κB)/P53/Toll-like receptor 4 (TLR4) signaling pathway in older patients with multiple peripheral artery occlusions. Results: The levels of MDA, F2-isoP, TOS, IMA, MIME, NF-κB, P53, and TLR4 were increased in the single-site peripheral artery occlusive group when compared with healthy controls (P < .001) and were further increased in the multiple-site peripheral artery occlusive group compared with the single-site peripheral artery occlusive group (P < .001). Conclusion: Oxidative stress may promote inflammatory signaling pathways and lead to multiple peripheral artery occlusions in elderly patients.
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Affiliation(s)
- Xia Li
- Xiamen Road Branch Hospital, 38044The Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
| | - Dianxuan Guo
- Xiamen Road Branch Hospital, 38044The Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
| | - Wenhang Zhou
- Xiamen Road Branch Hospital, 38044The Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
| | - Youdong Hu
- Xiamen Road Branch Hospital, 38044The Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
| | - Hualan Zhou
- Xiamen Road Branch Hospital, 38044The Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
| | - Ying Chen
- Xiamen Road Branch Hospital, 38044The Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
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Min X, Du J, Bai X, Wei T, Dmytriw AA, Patel AB, Zhang X, Xu X, Feng Y, Wang T, Wang X, Yang K, Hu W, Yi T, Chen W, Jiao L. Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2022; 12:757665. [PMID: 35095720 PMCID: PMC8790816 DOI: 10.3389/fneur.2021.757665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I 2 statistic. Subgroup and sensitivity analyses were also performed. Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, p = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. Systematic Review Registration: "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.
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Affiliation(s)
- Xiaoli Min
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital, Kunming Medical University, Kunming, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianhua Du
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wei
- Library, Kunming Medical University, Kunming, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiwu Hu
- Department of Neurology, The First Traditional Chinese Medicine Hospital of Chengde, Chengde, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Yu Z, Chen Z, Yu Y, Zhu H, Tong D, Chen Y. An automated ASPECTS method with atlas-based segmentation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 210:106376. [PMID: 34500140 DOI: 10.1016/j.cmpb.2021.106376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 08/21/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND PURPOSE As a simple and reliable systematic method to evaluate the early ischemic changes in the blood supply region of the middle cerebral artery of patients with ischemic stroke, the Alberta Stroke Program Early CT score (ASPECTS) can be used for rapid semi-quantitative evaluation of ischemic lesions, which is helpful to select potential candidates for intravenous and intra-arterial therapies, determine the thrombolytic effect and long-term prognosis. This method mainly relies on doctors' visual observation. However, due to different levels of doctor's experience, the poor inter-reader agreement may result in errors in the final ASPECTS. The purpose of this work was to propose an automated semi-quantitative method for the diagnosis of acute ischemic stroke based on non-contrast computed tomography (NCCT), to provide a reference for doctors in the diagnosis and evaluation. METHODS NCCT data from a total of 90 patients were included for auto-ASPECTS training and testing. After preprocessing CT images, the regions of interest (ROI) for ASPECTS were labeled using atlas-based segmentation. The mean difference, mean ratio and brain density shifts (BDS) of the corresponding regions of the contralateral brain were used as the standard for quantitative analysis. The auto-ASPECTS method was developed and validated to predict early ischemic changes whose performance was evaluated by the agreement (accuracy) of predictions and consensus scores of two observers. RESULTS A comparison was made among the results on mean difference, mean ratio, BDS and the combination of multiple parameters as the standard. The result of using BDS alone was relatively better than the result of using any other parameter alone or any combination of multiple parameters, and accuracy in the test set was 0.80. In the test set, accuracy with using different BDS thresholds increased by 6.67% compared with using the consistent BDS threshold. After dichotomy of auto-ASPECTS and consensus scores with the threshold of 7, the agreement of them was 83.3% and there was no significant difference between the two distributions (p = 0.344) in McNemar test. CONCLUSIONS The proposed auto-ASPECTS method for NCCT images can provide useful information for early diagnosis and evaluation of patients with acute ischemic stroke (AIS).
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Affiliation(s)
- Zechen Yu
- Laboratory of Image Science and Technology, Southeast University, Nanjing 210096, China; Key Laboratory of Computer Network and Information Integration (Southeast University), Ministry of Education, Nanjing 210096, China
| | - Zhongping Chen
- Department of Radiology, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Yang Yu
- Department of Radiology, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Haichen Zhu
- Laboratory of Image Science and Technology, Southeast University, Nanjing 210096, China; Key Laboratory of Computer Network and Information Integration (Southeast University), Ministry of Education, Nanjing 210096, China
| | - Dan Tong
- Department of Radiology, The First Hospital of Jilin University, Changchun, Jilin 130021, China.
| | - Yang Chen
- Laboratory of Image Science and Technology, Southeast University, Nanjing 210096, China; Key Laboratory of Computer Network and Information Integration (Southeast University), Ministry of Education, Nanjing 210096, China.
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Correia P, Machado S, Meyer I, Amiguet M, Eskandari A, Michel P. Ischemic stroke on hormonal contraceptives: Characteristics, mechanisms and outcome. Eur Stroke J 2021; 6:205-212. [PMID: 34414296 DOI: 10.1177/23969873211019586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/03/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Systemic contraceptives increase the risk of ischemic stroke but little is known about the characteristics, mechanisms and long-term outcome post stroke of patients on hormonal contraception. We sought to To assess characteristics and outcome of acute ischemic stroke (AIS) in young women using systemic hormonal contraceptives (SHC) and compare them to strokes in non-contraceptive users. Patients and methods Using the Acute STroke Registry and Analysis of Lausanne (ASTRAL), we analyzed demographics, risk factors, clinical, radiological and treatment data of consecutive female patients of <50 years between 2003 to 2015. We compared groups with and without SHC in a logistic regression analysis. Results Of the 179 female patients of <50 years during the observation period, 57 (39.6%) used SHC, 71.9% of whom, a combined oral contraceptive pill. On logistic regression contraceptive users were significantly younger but had comparable stroke severity. They had less migraine with aura and tobacco use, and more hyperlipidaemia. Also, contraceptive users had significantly less intra and extracranial stenosis and occlusion on arterial imaging, but more focal hypoperfusion on CT-perfusion. Undetermined mechanism of stroke was more frequent with SHC users, whereas rare mechanisms were more frequent in non-users. The contraceptive user group had a more favourable adjusted 12-month outcome with significantly fewer ischemic recurrences after stopping systemic contraception in all. Conclusion Contraceptive users with ischemic strokes are younger and have lesser tobacco use and migraine with aura and more hyperlipidemia. Their stroke mechanism is more often undetermined using a standardised work-up, and their adjusted long-term outcome is more favourable with less stroke recurrence.
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Affiliation(s)
- P Correia
- Department of Clinical Neurosciences, Stroke Centre, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland.,Stroke Unit, Neurology Service, Cantonal Hospital of Biel, Biel, Switzerland
| | - S Machado
- Department of Clinical Neurosciences, Stroke Centre, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland.,Neurology Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - I Meyer
- Department of Clinical Neurosciences, Stroke Centre, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland.,Stroke Unit, Neurology Service, Cantonal Hospital of Biel, Biel, Switzerland
| | - M Amiguet
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - A Eskandari
- Department of Clinical Neurosciences, Stroke Centre, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - P Michel
- Department of Clinical Neurosciences, Stroke Centre, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
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Branco JP, Rocha F, Sargento-Freitas J, Santo GC, Freire A, Laíns J, Páscoa Pinheiro J. Impact of Post-Stroke Recanalization on General and Upper Limb Functioning: A Prospective, Observational Study. Neurol Int 2021; 13:46-58. [PMID: 33557006 PMCID: PMC7931094 DOI: 10.3390/neurolint13010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/17/2021] [Accepted: 01/22/2021] [Indexed: 11/16/2022] Open
Abstract
The objective of this study is to assess the impact of recanalization (spontaneous and therapeutic) on upper limb functioning and general patient functioning after stroke. This is a prospective, observational study of patients hospitalized due to acute ischemic stroke in the territory of the middle cerebral artery (n = 98). Patients completed a comprehensive rehabilitation program and were followed-up for 24 weeks. The impact of recanalization on patient functioning was evaluated using the modified Rankin Scale (mRS) and Stroke Upper Limb Capacity Scale (SULCS). General and upper limb functioning improved markedly in the first three weeks after stroke. Age, gender, and National Institutes of Health Stroke Scale (NIHSS) score at admission were associated with general and upper limb functioning at 12 weeks. Successful recanalization was associated with better functioning. Among patients who underwent therapeutic recanalization, NIHSS scores ≥16.5 indicate lower general functioning at 12 weeks (sensibility = 72.4%; specificity = 78.6%) and NIHSS scores ≥13.5 indicate no hand functioning at 12 weeks (sensibility = 83.8%; specificity = 76.5%). Recanalization, either spontaneous or therapeutic, has a positive impact on patient functioning after acute ischemic stroke. Functional recovery occurs mostly within the first 12 weeks after stroke, with greater functional gains among patients with successful recanalization. Higher NIHSS scores at admission are associated with worse functional recovery.
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Affiliation(s)
- João Paulo Branco
- Physical and Rehabilitation Medicine Department, Centro Hospitalar Universitário de Coimbra, 3030-075 Coimbra, Portugal; (F.R.); (J.L.); (J.P.P.)
- Faculty of Medicine, University of Coimbra, 3030-075 Coimbra, Portugal; (J.S.-F.); (G.C.S.); (A.F.)
- Correspondence:
| | - Filipa Rocha
- Physical and Rehabilitation Medicine Department, Centro Hospitalar Universitário de Coimbra, 3030-075 Coimbra, Portugal; (F.R.); (J.L.); (J.P.P.)
| | - João Sargento-Freitas
- Faculty of Medicine, University of Coimbra, 3030-075 Coimbra, Portugal; (J.S.-F.); (G.C.S.); (A.F.)
- Neurology Department, Centro Hospitalar Universitário de Coimbra, 3030-075 Coimbra, Portugal
| | - Gustavo C. Santo
- Faculty of Medicine, University of Coimbra, 3030-075 Coimbra, Portugal; (J.S.-F.); (G.C.S.); (A.F.)
- Neurology Department, Centro Hospitalar Universitário de Coimbra, 3030-075 Coimbra, Portugal
| | - António Freire
- Faculty of Medicine, University of Coimbra, 3030-075 Coimbra, Portugal; (J.S.-F.); (G.C.S.); (A.F.)
- Neurology Department, Centro Hospitalar Universitário de Coimbra, 3030-075 Coimbra, Portugal
| | - Jorge Laíns
- Physical and Rehabilitation Medicine Department, Centro Hospitalar Universitário de Coimbra, 3030-075 Coimbra, Portugal; (F.R.); (J.L.); (J.P.P.)
| | - João Páscoa Pinheiro
- Physical and Rehabilitation Medicine Department, Centro Hospitalar Universitário de Coimbra, 3030-075 Coimbra, Portugal; (F.R.); (J.L.); (J.P.P.)
- Faculty of Medicine, University of Coimbra, 3030-075 Coimbra, Portugal; (J.S.-F.); (G.C.S.); (A.F.)
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Marto JP, Lambrou D, Eskandari A, Nannoni S, Strambo D, Saliou G, Maeder P, Sirimarco G, Michel P. Associated Factors and Long-Term Prognosis of 24-Hour Worsening of Arterial Patency After Ischemic Stroke. Stroke 2019; 50:2752-2760. [PMID: 31412758 DOI: 10.1161/strokeaha.119.025787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Early arterial recanalization in acute ischemic stroke is strongly associated with better outcomes. However, early worsening of arterial patency was seldom studied. We investigated potential predictors and long-term prognosis of worsening of arterial patency at 24 hours after stroke onset. Methods- Patients from the Acute Stroke Registry and Analysis of Lausanne registry including admission and 24-hour vascular imaging (computed tomography or magnetic resonance angiography) were included. Worsening of arterial patency was defined as a new occlusion and significant stenosis in any extracranial or intracranial artery, comparing 24 hours with admission imaging. Variables associated with worsening of arterial patency were assessed by stepwise multiple logistic regression. The impact of arterial worsening on 3-month outcome was investigated with an adjusted modified Rankin Scale shift analysis. Results- Among 2152 included patients, 1387 (64.5%) received intravenous thrombolysis and endovascular treatment, and 65 (3.0%) experienced 24-hour worsening of arterial patency. In multivariable analysis, history of hypertension seemed protective (adjusted odds ratio [aOR], 0.45; 95% CI, 0.27-0.75) while higher admission National Institutes of Health Stroke Scale (aOR, 1.06; 95% CI, 1.02-1.10), intracranial (aOR, 4.78; 95% CI, 2.03-11.25) and extracranial stenosis (aOR, 3.67; 95% CI, 1.95-6.93), and good collaterals (aOR, 3.71; 95% CI, 1.54-8.95) were independent predictors of worsening of arterial patency. Its occurrence was associated with a major unfavorable shift in the distribution of the modified Rankin Scale at 3 months (aOR, 5.97; 95% CI, 3.64-9.79). Conclusions- Stroke severity and admission vascular imaging findings may help to identify patients at a higher risk of developing worsening of arterial patency at 24 hours. The impact of worsening of arterial patency on long-term outcome warrants better methods to detect and prevent this early complication.
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Affiliation(s)
- João Pedro Marto
- From the Stroke Centre, Neurology Service, Department of Clinical Neurosciences (J.P.M., D.L., A.E., S.N., D.S., G. Sirimarco, P. Michel), Lausanne University Hospital, Switzerland.,Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (J.P.M.)
| | - Dimitris Lambrou
- From the Stroke Centre, Neurology Service, Department of Clinical Neurosciences (J.P.M., D.L., A.E., S.N., D.S., G. Sirimarco, P. Michel), Lausanne University Hospital, Switzerland
| | - Ashraf Eskandari
- From the Stroke Centre, Neurology Service, Department of Clinical Neurosciences (J.P.M., D.L., A.E., S.N., D.S., G. Sirimarco, P. Michel), Lausanne University Hospital, Switzerland
| | - Stefania Nannoni
- From the Stroke Centre, Neurology Service, Department of Clinical Neurosciences (J.P.M., D.L., A.E., S.N., D.S., G. Sirimarco, P. Michel), Lausanne University Hospital, Switzerland
| | - Davide Strambo
- From the Stroke Centre, Neurology Service, Department of Clinical Neurosciences (J.P.M., D.L., A.E., S.N., D.S., G. Sirimarco, P. Michel), Lausanne University Hospital, Switzerland
| | - Guillaume Saliou
- Neuroradiology Unit, Diagnostic and Interventional Radiology Service, Department of Radiology (G. Saliou, P. Maeder), Lausanne University Hospital, Switzerland
| | - Philippe Maeder
- Neuroradiology Unit, Diagnostic and Interventional Radiology Service, Department of Radiology (G. Saliou, P. Maeder), Lausanne University Hospital, Switzerland
| | - Gaia Sirimarco
- From the Stroke Centre, Neurology Service, Department of Clinical Neurosciences (J.P.M., D.L., A.E., S.N., D.S., G. Sirimarco, P. Michel), Lausanne University Hospital, Switzerland
| | - Patrik Michel
- From the Stroke Centre, Neurology Service, Department of Clinical Neurosciences (J.P.M., D.L., A.E., S.N., D.S., G. Sirimarco, P. Michel), Lausanne University Hospital, Switzerland
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Bernardo F, Nannoni S, Strambo D, Puccinelli F, Saliou G, Michel P, Sirimarco G. Efficacy and safety of endovascular treatment in acute ischemic stroke due to cervical artery dissection: A 15-year consecutive case series. Int J Stroke 2019; 14:381-389. [DOI: 10.1177/1747493018823161] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Limited observational data are available on endovascular treatment in acute ischemic stroke due to cervical artery dissection. Three studies comparing endovascular treatment with standard medical therapy or intravenous thrombolysis in cervical artery dissection-related acute ischemic stroke did not demonstrate superiority of endovascular treatment. Efficacy and the choice of endovascular treatment technique in this setting remain to be established. Aims To assess the potential efficacy and safety of endovascular treatment compared to intravenous thrombolysis alone or to no revascularization treatment in our center. Methods We selected all consecutive patients with cervical artery dissection-related acute ischemic stroke and intracranial occlusion from the Acute STroke Registry and Analysis of Lausanne between 2003 and 2017. We compared clinical and neuroimaging data of patients treated by endovascular treatment versus patients receiving intravenous thrombolysis or patients without revascularization treatment. Safety analysis included symptomatic intracranial hemorrhage, major radiological hemorrhages (parenchymal hematoma 1, parenchymal hematoma 2, and subarachnoid hemorrhage) and mortality within seven days. We assessed favorable clinical outcome (modified Rankin Scale 0-2) at three months using a binary logistic regression model. Results Of the 109 patients included, 24 had endovascular treatment, 38 received intravenous thrombolysis alone, and 47 had no revascularization treatment. Endovascular treatment patients had a higher rate of recanalization at 24 h. Major radiological hemorrhages occurred more often in endovascular treatment patients (all with bridging therapy) than in patients without revascularization treatment (p = 0.026), with no differences in symptomatic intracranial hemorrhage or mortality within seven days. Favorable clinical outcome at three months did not differ between groups (endovascular treatment versus intravenous thrombolysis p = 0.407; endovascular treatment versus no revascularization treatment p = 0.580). Conclusions In this single-center cohort of cervical artery dissection-related acute ischemic stroke with intracranial occlusion, endovascular treatment with prior intravenous thrombolysis may increase the risk of major radiological but not symptomatic intracranial hemorrhage. Despite the lack of clear superiority in our cohort, endovascular treatment should currently not be withheld in these patients.
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Affiliation(s)
- Francisco Bernardo
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
- Department of Neurology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Francesco Puccinelli
- Interventional Neuroradiology Unit, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Guillaume Saliou
- Interventional Neuroradiology Unit, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Gaia Sirimarco
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
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Differences in Ischemic Anterior and Posterior Circulation Strokes: A Clinico-Radiological and Outcome Analysis. J Stroke Cerebrovasc Dis 2018; 28:710-718. [PMID: 30501979 DOI: 10.1016/j.jstrokecerebrovasdis.2018.11.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/30/2018] [Accepted: 11/08/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are limited data comparing posterior (PC) and anterior (AC) circulation acute ischemic strokes (AIS). We aimed to identify specific features of PC and AC strokes regarding clinical, etiological, radiological, and outcome factors. METHODS Patients from the Acute STroke Registry and Analysis of Lausanne, a prospective cohort of consecutive AIS, from years 2003 to 2008 were included. The stroke territory was determined by a combination of neuroimaging and clinical symptoms. Patients with uncertain localization or with simultaneous AC and PC strokes were excluded. Multivariate associations between territory and multiple variables were investigated. RESULTS A total of 1449 patients were included, 466 (32.2%) had a PC territory stroke and 983 (67.8%) an AC. On multivariate analysis, those with PC AIS had lower National Institutes of Health Stroke Scale at admission, more often showed decreased consciousness, visual field defects, and vestibulo-cerebellar signs, but less hemisyndromes, dysarthria, and cognitive symptoms compared to AC AIS patients. Male sex, arterial dissection, lacunar mechanisms, and endovascular recanalization were more frequent in PC strokes, whereas cardioembolic strokes and IV-thrombolysis rates were lower. Less early ischemic signs on admission CT, overall arterial pathology, and 24-hour recanalization were present in PC strokes but intracranial arterial pathology was more prevalent than in AC. The adjusted clinical outcome at 3 months was similar in both groups. CONCLUSIONS In this large retrospective consecutive AIS series, there were specific differences in clinical presentation, etiology, and arterial pathology between PC and AC strokes which did not influence clinical outcome. These findings could lead to a tailored diagnostic work-up, acute treatment strategies, and secondary prevention.
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11
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Sugrue G, O'Reilly MK, Byrne D, Crockett MT, Murphy S, Kavanagh EC. CT cervico-cerebral angiography in acute stroke. Can we justify aortic arch imaging? Ir J Med Sci 2018; 188:661-666. [PMID: 30143966 DOI: 10.1007/s11845-018-1888-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 08/14/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Computed tomography cervico-cerebral angiography (CTCCA) plays a pivotal role in the evaluation of acute stroke. Currently no evidence justifies the inclusion of the upper chest in the CTCCA field of view. The aim of this study was to assess the prevalence and clinical significance of vascular findings identified on CTCCA in the head, neck, and upper chest regions in patients presenting with acute stroke symptoms. METHODS A retrospective review of radiology images and reports of 900 consecutive patients (425 men, 475 women; mean age 63.2 years, age range 19-99 years) with a suspected acute stroke who underwent CTCCA in the emergency department between January 2011 and July 2016. Clinically significant vascular CTCCA findings were recorded for each patient within the head, neck, and upper chest regions, respectively. RESULTS Of the 900 patients, clinically significant vascular CTCCA findings were identified in 404/900 (44.8%) patients. 218/900 (24.2%) were located within the head region; 174/900 (19.3%) within the neck; and 12/900 (2.4%) in the upper chest. Of the 12 vascular findings located within the upper chest, 3/900 (0.33%) were related to a clinically significant posterior circulation infarct. CONCLUSIONS Routine inclusion of the upper chest on CTCCA is currently difficult to justify in the evaluation of a suspected acute anterior circulation stroke, contributing significantly to total radiation dose without demonstrating significant extra-cranial vascular findings. Prospective studies adopting narrower fields of view excluding the upper chest are necessary.
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Affiliation(s)
- Gavin Sugrue
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland.
| | - Michael K O'Reilly
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Danielle Byrne
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Matthew T Crockett
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Sean Murphy
- Department of Stroke Medicine, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Eoin C Kavanagh
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland
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Wu YM, Zhai YD, Zhou YT, Tang SM, Li XY, Jia LF, Meng XB, Zhang H, Sun GB, Sun XB. Protection of Shuxuetong combined with aspirin against cerebral ischemia/reperfusion injury through ameliorating coagulation and fibrinolysis system. CHINESE HERBAL MEDICINES 2018. [DOI: 10.1016/j.chmed.2018.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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13
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Heldner MR, Seiffge D, Mueller H, Eskandari A, Traenka C, Ntaios G, Mosimann PJ, Sztajzel R, Pereira VM, Cras P, Engelter S, Lyrer P, Fischer U, Lambrou D, Arnold M, Michel P, Vanacker P. ASTRAL-R score predicts non-recanalisation after intravenous thrombolysis in acute ischaemic stroke. Thromb Haemost 2017; 113:1121-6. [DOI: 10.1160/th14-06-0482] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 11/21/2014] [Indexed: 11/05/2022]
Abstract
SummaryIntravenous thrombolysis (IVT) as treatment in acute ischaemic strokes may be insufficient to achieve recanalisation in certain patients. Predicting probability of non-recanalisation after IVT may have the potential to influence patient selection to more aggressive management strategies. We aimed at deriving and internally validating a predictive score for post-thrombolytic non-recanalisation, using clinical and radiological variables. In thrombolysis registries from four Swiss academic stroke centres (Lausanne, Bern, Basel and Geneva), patients were selected with large arterial occlusion on acute imaging and with repeated arterial assessment at 24 hours. Based on a logistic regression analysis, an integer-based score for each covariate of the fitted multivariate model was generated. Performance of integerbased predictive model was assessed by bootstrapping available data and cross validation (delete-d method). In 599 thrombolysed strokes, five variables were identified as independent predictors of absence of recanalisation: Acute glucose > 7 mmol/l (A), significant extracranial vessel STenosis (ST), decreased Range of visual fields (R), large Arterial occlusion (A) and decreased Level of consciousness (L). All variables were weighted 1, except for (L) which obtained 2 points based on β-coefficients on the logistic scale. ASTRAL-R scores 0, 3 and 6 corresponded to non-recanalisation probabilities of 18, 44 and 74 % respectively. Predictive ability showed AUC of 0.66 (95 %CI, 0.61–0.70) when using bootstrap and 0.66 (0.63–0.68) when using delete-d cross validation. In conclusion, the 5-item ASTRAL-R score moderately predicts non-recanalisation at 24 hours in thrombolysed ischaemic strokes. If its performance can be confirmed by external validation and its clinical usefulness can be proven, the score may influence patient selection for more aggressive revascularisation strategies in routine clinical practice.
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Maus V, Behme D, Borggrefe J, Kabbasch C, Seker F, Hüseyin C, Barnikol UB, Yeo LLL, Brouwer P, Söderman M, Möhlenbruch M, Psychogios MN, Liebig T, Dohmen C, Fink GR, Mpotsaris A. Carotid Artery Stenosis Contralateral to Acute Tandem Occlusion: An Independent Predictor of Poor Clinical Outcome after Mechanical Thrombectomy with Concomitant Carotid Artery Stenting. Cerebrovasc Dis 2017; 45:10-17. [PMID: 29208850 DOI: 10.1159/000484719] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral ischemic strokes due to extra-/intracranial tandem occlusions (TO) of the anterior circulation are responsible for causing mechanical thrombectomy (MT). The impact of concomitant contralateral carotid stenosis (CCS) upon outcome remains unclear in this stroke subtype. METHODS Retrospective analysis of prospectively collected data of 4 international stroke centers between 2011 and 2017. One hundred ninety-seven consecutive patients with anterior TO were treated with MT and acute carotid artery stenting (CAS). Clinical (including demographics and National Institutes of Health Stroke Scale [NIHSS]), imaging (including angiographic evaluation of CCS) and procedural data were evaluated. Favorable clinical outcome was defined as modified Rankin Scale (mRS) ≤2 at 90 days. RESULTS In 186 out of 197 TO patients preinterventional CT angiography was available for analysis, thereof 49 patients (26%) presented with CCS. Median admission NIHSS and procedural timings did not differ between groups. Reperfusion was successful in 38 out of 49 patients (78%) vs. 113 out of 148 patients (76%) without CCS. In stark contrast, rate of favorable outcome at 90 days differed significantly between groups (22 vs. 44%; p < 0.05). The presence of CCS in TO was associated with an unfavorable clinical outcome independent of age and NIHSS in multivariate logistic regression (p < 0.05). Final infarct volume was significantly larger in CCS patients (100 ± 127 vs. 63 ± 77 cm3; p < 0.05). Neither all-cause mortality rates (25 vs. 17%) nor frequency of peri-interventional symptomatic intracranial hemorrhage differed between groups (7 vs. 6%). CONCLUSION For patients with anterior TO undergoing MT with concomitant CAS the presence of CCS >50% is an independent predictor of poor clinical outcome. This most likely cause is due to poorer collateral flow to the affected tissue.
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Affiliation(s)
- Volker Maus
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Jan Borggrefe
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Fatih Seker
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Cicek Hüseyin
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Utako Birgit Barnikol
- Clearing Unit Ethics, Medical Faculty of Cologne and Research Unit Ethics, Department of Child and Adolescence Psychiatry, University Hospital of Cologne, Cologne, Germany
| | - Leonard Leong Litt Yeo
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Patrick Brouwer
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Söderman
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Markus Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Christian Dohmen
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Gereon Rudolf Fink
- Department of Neurology, University Hospital Cologne, Cologne, Germany.,Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich, Jülich, Germany
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15
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Maus V, You S, Kalkan A, Borggrefe J, Kabbasch C, Barnikol UB, Stetefeld H, Dohmen C, Liebig T, Fink GR, Mpotsaris A. Incomplete Large Vessel Occlusions in Mechanical Thrombectomy: An Independent Predictor of Favorable Outcome in Ischemic Stroke. Cerebrovasc Dis 2017; 44:113-121. [PMID: 28605743 DOI: 10.1159/000477499] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/11/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral large vessel occlusion (LVO) in acute ischemic stroke (AIS) may be complete (CLVO) or incomplete (ILVO). The influence of ILVO on clinical outcome after mechanical thrombectomy (MT) remains unclear. We investigated primarily the clinical outcome in patients with AIS due to ILVO or CLVO. METHODS Five hundred three consecutive AIS patients with LVO treated with stent-retriever or direct aspiration-based MT between 2010 and 2016 were analyzed. The primary endpoint was favorable clinical outcome (modified Rankin Scale ≤2) at 90 days; secondary endpoints were periprocedural parameters. RESULTS Forty-nine patients (11.3%) with a median National Institutes of Health Stroke Scale (NIHSS) of 11 presented with ILVO and the remainder presented with CLVO and median NIHSS of 15 (p < 0.001). The median groin puncture-to-reperfusion time was 30 vs. 67 min, respectively (p < 0.001). Successful reperfusion was reached in 47 out of 49 ILVO (95.9%) vs. 298 out of 381 CLVO (78.2%; p < 0.005) with less retrieval maneuvers (1.7 ± 2.2 vs. 3.0 ± 2.5; p < 0.001). The favorable outcome at 90 days was 81% in patients with ILVO vs. 29.1% in CLVO (p < 0.001); respective all-cause mortality rates were 6.4 vs. 28.5% (p < 0.001). Periprocedural complications (6.9%) occurred exclusively in CLVO patients (p < 0.05). ILVO was associated with favorable clinical outcome independent of age and NIHSS in multivariate logistic regression both in the anterior (OR 3.6; 95% CI 1.8-6.9; p < 0.001) and posterior circulation (OR 3.5; 95% CI 1.8-6.9; p < 0.001). CONCLUSIONS AIS due to ILVO is frequent and is associated with a nearly threefold higher chance of favorable clinical outcome at 90 days, independent of age and initial NIHSS compared to CLVO.
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Affiliation(s)
- Volker Maus
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
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Rotzinger DC, Mosimann PJ, Meuli RA, Maeder P, Michel P. Site and Rate of Occlusive Disease in Cervicocerebral Arteries: A CT Angiography Study of 2209 Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2017; 38:868-874. [PMID: 28302611 DOI: 10.3174/ajnr.a5123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/13/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CTA can rapidly and accurately detect and localize occlusive disease in patients with ischemic stroke. We have used CTA to assess arterial stenosis and occlusion in an ischemic stroke population arriving at a tertiary stroke center within 24 hours of symptom onset in order to obtain a comprehensive picture of occlusive disease pattern, and to determine the proportion of eligible candidates for endovascular treatment. MATERIALS AND METHODS Data from consecutive patients with acute ischemic stroke admitted to a single center between 2003 and 2012, collected in the Acute Stroke Registry and Analysis of Lausanne data base, were retrospectively analyzed. Patients with a diagnostic CTA within 24 hours of symptom onset were selected. Relevant extra- and intracranial pathology, defined as stenosis of ≥50% and occlusions, were registered and classified into 21 prespecified segments. RESULTS Of the 2209 included patients (42.1% women; median age, 72 years), 1075 (48.7%) had pathology in and 308 (13.9%) had pathology outside the ischemic territory. In the 50,807 arterial segments available for revision, 1851 (3.6%) abnormal segments were in the ischemic (symptomatic) territory and another 408 (0.8%) were outside it (asymptomatic). In the 1211 patients with ischemic stroke imaged within 6 hours of symptom onset, 40.7% had symptomatic large, proximal occlusions potentially amenable to endovascular therapy. CONCLUSIONS CTA in patients with acute ischemic stroke shows large individual variations of occlusion sites and degrees. Approximately half of such patients have no visible occlusive disease, and 40% imaged within 6 hours show large, proximal segment occlusions amenable to endovascular therapy. These findings show the importance of early noninvasive imaging of extra- and intracranial arteries for identifying occlusive disease, planning recanalization strategies, and designing interventional trials.
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Affiliation(s)
- D C Rotzinger
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P J Mosimann
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - R A Meuli
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P Maeder
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P Michel
- Neurology Service (P. Michel), Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Severe cerebral hypovolemia on perfusion CT and lower body weight are associated with parenchymal haemorrhage after thrombolysis. Neuroradiology 2016; 59:23-29. [PMID: 28028565 DOI: 10.1007/s00234-016-1775-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Haemorrhagic transformation of acute ischemic stroke (AIS) and particularly parenchymal haemorrhage (PH) remains a feared complication of intravenous thrombolysis (IVT). We aimed to identify clinical and perfusion CT (PCT) variables which are independently associated with PHs. METHODS In this observational cohort study, based on the Acute Stroke Registry Analysis of Lausanne (ASTRAL) from 2003 to December 2013, we selected patients with AIS involving the middle cerebral artery (MCA) territory who were thrombolysed within 4.5 h of symptoms' onset and who had a good quality baseline PCT at the beginning of IVT. In addition to demographic, clinical, laboratory and non-contrast CT data, volumes of salvageable tissue and ischemic core on PCT, as well as absolute CBF and CBV values within the ischemic regions were compared in patients with and without PH in multivariate analysis. RESULTS Of the 190 included patients, 24 (12.6%) presented a PH (11 had PH1 and 13 had PH2). In multivariate analysis of the clinical and radiological variables, the lowest CBV in the core and lower body weight was both significantly associated with PH (p = 0.009 and p = 0.024, respectively). CONCLUSION In thrombolysed MCA strokes, maximal hypoperfusion severity depicted by lowest CBV values in the core region and lower body weight are independently correlated with PH. This information, if confirmed in other case series, may add to the stratification of revascularisation decisions in patients with a perceived high PH risk.
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Linfante I, Cipolla MJ. Improving Reperfusion Therapies in the Era of Mechanical Thrombectomy. Transl Stroke Res 2016; 7:294-302. [PMID: 27221511 PMCID: PMC4929023 DOI: 10.1007/s12975-016-0469-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 05/08/2016] [Accepted: 05/10/2016] [Indexed: 12/27/2022]
Abstract
Recent positive clinical trials using mechanical thrombectomy proved that endovascular recanalization is an effective treatment for patients with acute stroke secondary to large vessel occlusions. The trials offer definite evidence that in acute ischemia recanalization is a powerful predictor of good outcome. However, even in the era of rapid and effective recanalization using endovascular approaches, the percentage of patients with good outcomes varies between 33 and 71 %. In addition, the number of patients who are eligible for endovascular thrombectomy is small and usually based on having salvageable tissue on imaging. There is therefore room for improvement to both enhance the effectiveness of current practice and expand treatment to a larger subset of stroke patients. In this review, we highlight some of the most promising approaches to improve endovascular therapy by combining with strategies to enhance collateral perfusion and vascular protection.
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Affiliation(s)
- Italo Linfante
- Miami Cardiac and Vascular Institute and Neuroscience Center, Baptist Hospital, Miami, FL, USA
| | - Marilyn J Cipolla
- Department of Neurological Sciences and Pharmacology, University of Vermont College of Medicine, 149 Beaumont Ave.; HSRF 416A, Burlington, VT, 05405, USA.
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Eligibility and Predictors for Acute Revascularization Procedures in a Stroke Center. Stroke 2016; 47:1844-9. [DOI: 10.1161/strokeaha.115.012577] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 05/17/2016] [Indexed: 01/19/2023]
Abstract
Background and Purpose—
Endovascular treatment (EVT) is a new standard of care for selected, large vessel occlusive strokes. We aimed to determine frequency of potentially eligible patients for intravenous thrombolysis (IVT) and EVT in comprehensive stroke centers. In addition, predictors of EVT eligibility were derived.
Methods—
Patients from a stroke center–based registry (2003–2014), admitted within 24 hours of last proof of usual health, were selected if they had all data to determine IVT and EVT eligibility according to American Heart Association/American Stroke Association (AHA/ASA) guidelines (class I–IIa recommendations). Moreover, less restrictive criteria adapted from randomized controlled trials and clinical practice were tested. Maximum onset-to-door time windows for IVT eligibility were 3.5 hours (allowing door-to-needle delay of ≤60 minutes) and 4.5 hours for EVT eligibility (door-to-groin delay ≤90 minutes). Demographic and clinical information were used in logistic regression analysis to derive variables associated with EVT eligibility.
Results—
A total of 2704 patients with acute ischemic stroke were included, of which 26.8% were transfers. Of all patients with stroke arriving at our comprehensive stroke center, a total proportion of 12.4% patients was eligible for IVT. Frequency of EVT eligibility differed between AHA/ASA guidelines and less restrictive approach: 2.9% versus 4.9%, respectively, of all patients with acute ischemic stroke and 10.5% versus 17.7%, respectively, of all patients arriving within <6 hours. Predictors for AHA–EVT eligibility were younger, shorter onset-to-admission delays, higher National Institutes of Health Stroke Scale (NIHSS), decreased vigilance, hemineglect, absent cerebellar signs, atrial fibrillation, smoking, and decreasing glucose levels (area under the curve=0.86).
Conclusions—
Of patients arriving within 6 hours at a comprehensive stroke center, 10.5% are EVT eligible according to AHA/ASA criteria, 17.7% according to criteria resembling randomized controlled trials, and twice as many patients are IVT eligible (36.2%).
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Vanacker P, Lambrou D, Eskandari A, Ntaios G, Cras P, Maeder P, Meuli R, Michel P. Improving the Prediction of Spontaneous and Post-thrombolytic Recanalization in Ischemic Stroke Patients. J Stroke Cerebrovasc Dis 2015; 24:1781-6. [PMID: 26015095 DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/17/2015] [Accepted: 04/01/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endovascular treatment for acute ischemic stroke patients was recently shown to improve recanalization rates and clinical outcome in a well-defined study population. Intravenous thrombolysis (IVT) alone is insufficiently effective to recanalize in certain patients or of little value in others. Accordingly, we aimed at identifying predictors of recanalization in patients treated with or without IVT. METHODS In the observational Acute Stroke Registry and Analysis of Lausanne (ASTRAL) registry, we selected those stroke patients (1) with an arterial occlusion on computed tomography angiography (CTA) imaging, (2) who had an arterial patency assessment at 24 hours (CTA/magnetic resonance angiography/transcranial Doppler), and (3) who were treated with IVT or had no revascularization treatment. Based on 2 separate logistic regression analyses, predictors of spontaneous and post-thrombolytic recanalization were generated. RESULTS Partial or complete recanalization was achieved in 121 of 210 (58%) thrombolyzed patients. Recanalization was associated with atrial fibrillation (odds ratio , 1.6; 95% confidence interval, 1.2-3.0) and absence of early ischemic changes on CT (1.1, 1.1-1.2) and inversely correlated with the presence of a significant extracranial (EC) stenosis or occlusion (.6, .3-.9). In nonthrombolyzed patients, partial or complete recanalization was significantly less frequent (37%, P < .01). The recanalization was independently associated with a history of hypercholesterolemia (2.6, 1.2-5.6) and the proximal site of the intracranial occlusion (2.5, 1.2-5.4), and inversely correlated with a decreased level of consciousness (.3, .1-.8), and EC (.3, .1-.6) and basilar artery pathology (.1, .0-.6). CONCLUSIONS Various clinical findings, cardiovascular risk factors, and arterial pathology on acute CTA-based imaging are moderately associated with spontaneous and post-thrombolytic arterial recanalization at 24 hours. If confirmed in other studies, this information may influence patient selection toward the most appropriate revascularization strategy.
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Affiliation(s)
- Peter Vanacker
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Neurology, University Hospital Antwerp, Edegem, Belgium.
| | - Dimitris Lambrou
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Ashraf Eskandari
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Patrick Cras
- Department of Neurology, University Hospital Antwerp, Edegem, Belgium
| | - Philippe Maeder
- Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Reto Meuli
- Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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