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Leslie-Mazwi TM. Neurocritical Care for Patients With Ischemic Stroke. Continuum (Minneap Minn) 2024; 30:611-640. [PMID: 38830065 DOI: 10.1212/con.0000000000001427] [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: 06/05/2024]
Abstract
OBJECTIVE Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted. LATEST DEVELOPMENTS The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed. ESSENTIAL POINTS This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.
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Diprose JP, Diprose WK, Chien TY, Wang MTM, McFetridge A, Tarr GP, Ghate K, Beharry J, Hong J, Wu T, Campbell D, Barber PA. Deep learning on pre-procedural computed tomography and clinical data predicts outcome following stroke thrombectomy. J Neurointerv Surg 2024:jnis-2023-021154. [PMID: 38527795 DOI: 10.1136/jnis-2023-021154] [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: 10/18/2023] [Accepted: 02/23/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Deep learning using clinical and imaging data may improve pre-treatment prognostication in ischemic stroke patients undergoing endovascular thrombectomy (EVT). METHODS Deep learning models were trained and tested on baseline clinical and imaging (CT head and CT angiography) data to predict 3-month functional outcomes in stroke patients who underwent EVT. Classical machine learning models (logistic regression and random forest classifiers) were constructed to compare their performance with the deep learning models. An external validation dataset was used to validate the models. The MR PREDICTS prognostic tool was tested on the external validation set, and its performance was compared with the deep learning and classical machine learning models. RESULTS A total of 975 patients (550 men; mean±SD age 67.5±15.1 years) were studied with 778 patients in the model development cohort and 197 in the external validation cohort. The deep learning model trained on baseline CT and clinical data, and the logistic regression model (clinical data alone) demonstrated the strongest discriminative abilities for 3-month functional outcome and were comparable (AUC 0.811 vs 0.817, Q=0.82). Both models exhibited superior prognostic performance than the other deep learning (CT head alone, CT head, and CT angiography) and MR PREDICTS models (all Q<0.05). CONCLUSIONS The discriminative performance of deep learning for predicting functional independence was comparable to logistic regression. Future studies should focus on whether incorporating procedural and post-procedural data significantly improves model performance.
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Affiliation(s)
| | - William K Diprose
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Michael T M Wang
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andrew McFetridge
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Gregory P Tarr
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Kaustubha Ghate
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - James Beharry
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - JaeBeom Hong
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Doug Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - P Alan Barber
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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Zarrintan A, Ibrahim MK, Hamouda N, Jabal MS, Beizavi Z, Ghozy S, Kallmes DF. Region-specific interobserver agreement of the Alberta Stroke Program Early Computed Tomography Score: A meta-analysis. J Neuroimaging 2024; 34:195-204. [PMID: 38185754 DOI: 10.1111/jon.13184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/16/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND AND PURPOSE The Alberta Stroke Program Early CT Score (ASPECTS) is a widely used scoring system for evaluating ischemic stroke to determine therapeutic strategy. However, there is variation in the interobserver agreement of ASPECTS. This systematic review and meta-analysis aimed to investigate the interobserver agreement of total and regional ASPECTS. METHODS A comprehensive search was conducted in the Web of Sciences, PubMed, and Scopus databases to identify relevant studies. Inclusion criteria were studies of noncontrast CT performed within 24 hours of ischemic stroke in the middle cerebral artery territory. RESULTS A total of 20 studies, with 3482 patients, reporting interobserver agreement of total and regional ASPECTS were included in the meta-analysis. The interobserver agreement for total ASPECTS in studies using Kappa coefficient (κ) analysis was substantial (κ = .67, 95% confidence interval [CI]: .57-.78). In studies using intraclass correlation coefficient (ICC) analysis, agreement was excellent (ICC = .84, 95% CI: .77-.90). Interobserver agreement was higher in studies in which the observer was unblinded to clinical scenario in both groups (κ = .74, 95% CI: .59-.89, and ICC = .82, 95% CI: .79-.85). Per-region analysis showed that the caudate nucleus had the highest agreement (κ = .68, 95% CI: .60-.76, and ICC = .84, 95% CI: .74-.93), while M2 and internal capsule in Kappa studies (κ = .45, 95% CI: .34-.55 and κ = .47, 95% CI: .28-.66), and M4 and internal capsule in ICC studies (ICC = .54, 95% CI: .43-.64 and ICC = .55, 95% CI: .18-.91) had the lowest agreement. CONCLUSION This meta-analysis demonstrates substantial to excellent interobserver agreement for total ASPECTS, which supports using this method for stroke treatment. However, findings emphasize the need to consider interobserver agreement in specific regions of ASPECTS for treatment decisions.
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Affiliation(s)
- Armin Zarrintan
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Noha Hamouda
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Zahra Beizavi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Al-Mufti F, Marden FA, Burkhardt JK, Raper D, Schirmer CM, Baker A, Chen PR, Bulsara KR, Narsinh KH, Amans MR, Cooper J, Yaghi S, Al-Kawaz M, Hetts SW. Endovascular therapy for anterior circulation emergent large vessel occlusion stroke in patients with large ischemic cores: a report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg 2024:jnis-2023-021444. [PMID: 38395601 DOI: 10.1136/jnis-2023-021444] [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: 01/03/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Early clinical trials validating endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) ischemic stroke in the anterior circulation initially focused on patients with small or absent completed infarctions (ischemic cores) to maximize the probability of detecting a clinically meaningful and statistically significant benefit of EVT. Subsequently, real-world experience suggested that patients with large core ischemic strokes (LCS) at presentation may also benefit from EVT. Several large, retrospective, and prospective randomized clinical trials have recently been published that further validate this approach. These guidelines aim to provide an update for endovascular treatment of LCS. METHODS A structured literature review of LCS studies available since 2019 and grading the strength and quality of the evidence was performed. Recommendations were made based on these new data by consensus of the authors, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The management of ELVO strokes with large ischemic cores continues to evolve. The expert panel agreed on several recommendations: Recommendation 1: In patients with anterior circulation ELVO who present within 24 hours of last known normal with large infarct core (70-149 mL or ASPECTS 3-5) and meet other criteria of RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT, TESLA, TENSION, or LASTE trials, thrombectomy is indicated (Class I, Level A). Recommendations 2-7 flow directly from recommendation 1. Recommendation 2: EVT in patients with LCS aged 18-85 years is beneficial (Class I, Level A). Recommendation 3: EVT in patients with LCS >85 years of age may be beneficial (Class I, Level B-R). Recommendation 4: Patients with LCS and NIHSS score 6-30 benefit from EVT in LCS (Class I, Level A). Recommendation 5: Patients with LCS and NIHSS score <6 and >30 may benefit from EVT in LCS (Class IIa, Level A). Recommendation 6: Patients with LCS and low baseline mRS (0-1) benefit from EVT (Class I, Level A). Recommendation 7: Patients with LCS and time of last known well 0-24 hours benefit from EVT (Class I, Level A). Recommendation 8: It is recommended that patients with ELVO LCS who also meet the criteria for on-label or guideline-directed use of IV thrombolysis receive IV thrombolysis, irrespective of whether endovascular treatments are being considered (Class I, Level B-NR). CONCLUSIONS The indications for endovascular treatment of ELVO strokes continue to expand and now include patients with large ischemic cores on presentation. Further prospective randomized studies, including follow-up to assess the population-based efficacy of treating patients with LCS, are warranted.
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Affiliation(s)
- Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Franklin A Marden
- Interventional Neuroradiology, Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Raper
- Departments of Neurological Surgery, Radiology, and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
| | - Amanda Baker
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| | - Peng Roc Chen
- Neurosurgery, The University of Texas Health Science Center at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Kazim H Narsinh
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthew Robert Amans
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
- Department of Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mais Al-Kawaz
- Departments of Neurology, Neurosurgery, and Radiology, University of Kentucky, Lexington, Kentucky, USA
- Mount Sinai Health System, New York, New York, USA
| | - Steven W Hetts
- Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
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Thanki S, Pressman E, Jones KM, Skanes R, Armouti A, Guerrero WR, Vakharia K, Parthasarathy AB, Fargen K, Mistry EA, Nimjee SM, Hassan AE, Mokin M. Patients' perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke. Interv Neuroradiol 2024:15910199241227262. [PMID: 38258391 DOI: 10.1177/15910199241227262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The modified Rankin Scale (mRS) is a clinician-reported scale that measures the degree of disability in patients who suffered a stroke. Patients' perception of a meaningful recovery from severe stroke, expected value of a stroke intervention, and the effect of disparities are largely unknown. METHODS We conducted a survey of patients, their family members, and accompanying visitors to understand their personal preferences and expectations for acute strokes potentially eligible for acute endovascular intervention using a hypothetical scenario of a severe stroke in a standardized questionnaire. RESULTS Of 164 survey respondents, 65 (39.6%) were the patient involved, 93 (56.7%) were a family member, and six (3.7%) were accompanied visitors (friends, other). Minimally acceptable disability after a stroke intervention was considered as mRS 2 by 42 respondents (25.6%), as mRS 3 by 79 (48.2%), and as mRS 4 by 43 (26.2%) respondents. Race was associated with different views on this question (p < 0.001; Hispanic and Black patients being more likely to accept disability than Caucasian and Asian patients), while sex (p = 0.333) and age (p = 0.560) were not. Sixty-three respondents (38.4%) viewed minimally acceptable probability of improvement with an intervention as over 50%, 57 (34.8%) as 10-50%, and 44 (26.8%) as less than 10%. CONCLUSIONS A wide range of acceptable outcomes were reported regardless of gender or age. However, race was associated with different acceptable outcome. This is an important finding to demonstrate because of the persistent racial and ethnic disparities in the utilization of endovascular therapy for acute stroke in the United States.
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Affiliation(s)
- Shail Thanki
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Kassandra M Jones
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Ruby Skanes
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Ahmad Armouti
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Waldo R Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Kunal Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | | | - Kyle Fargen
- Department of Neurological Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Shahid M Nimjee
- Department of Neurosurgery, The Ohio State University Medical Center, Columbus, OH, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Harlingen, TX, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
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Hetts SW, Al-Mufti F, Dabus G, Fifi JT, Mocco J, Jayaraman MV. Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: large core and basilar artery occlusion patients. J Neurointerv Surg 2024; 16:113-114. [PMID: 37479479 DOI: 10.1136/jnis-2023-020763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Steven W Hetts
- Radiology, University of California San Francisco (UCSF), Biomedical Imaging and Neurological Surgery, San Francisco, California, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | | | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Mount Sinai Health System, New York, New York, USA
| | - Mahesh V Jayaraman
- Diagnostic Imaging, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
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Radu RA, Gascou G, Machi P, Capirossi C, Costalat V, Cagnazzo F. Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes. Eur J Radiol Open 2023; 11:100536. [PMID: 37964786 PMCID: PMC10641156 DOI: 10.1016/j.ejro.2023.100536] [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: 05/28/2023] [Revised: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Stroke Unit, Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregory Gascou
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, University of Geneva Medical Center, Switzerland
| | - Carolina Capirossi
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Department of Neurointerventional Radiology, Careggi Hospital, Florence, Italy
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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