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Sequeiros JM, Rodriguez-Calienes A, Chavez-Malpartida SS, Morán-Mariños C, Alvarado-Gamarra G, Malaga M, Quincho-Lopez A, Hernadez-Fernandez W, Pacheco-Barrios K, Ortega-Gutierrez S, Hoit D, Arthur AS, Alexandrov AV, Alva-Diaz C, Elijovich L. Stroke imaging modality for endovascular therapy in the extended window: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e46-e53. [PMID: 35725306 DOI: 10.1136/neurintsurg-2022-018896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND In anterior circulation large vessel occlusion (LVO) in the extended time window, the guidelines recommend advanced imaging (ADVI) to select patients for endovascular therapy (EVT). However, questions remain regarding its availability and applicability in the real world. It is unclear whether an approach to the extended window EVT that does not use ADVI would be equivalent. METHODS In April 2022, a literature search was performed to identified randomized controlled trials (RCT) and observational studies describing 90-day outcomes. We performed a meta-analysis of the proportion of aggregate using a random effect to estimate rates of functional independence, defined as modified Rankin Scale (mRS) score ≤2 at 90 days, mean mRS, mortality and symptomatic intracranial hemorrhage (sICH) stratified by imaging modality. RESULTS Four RCTs and 28 observational studies were included. The pooled proportion of functional independence among patients selected by ADVI was 44% (95% CI 39% to 48%; I2=80%) and 48% (95% CI 41% to 55%; I2=75%) with non-contrast CT/CT angiography (NCCT/CTA) (p=0.36). Mean mRS with ADVI was 2.88 (95% CI 2.36 to 3.41; I2=0.0%) and 2.79 (95% CI 2.31 to 3.27; I2=0.0%) with NCCT (p=0.79). Mortality in patients selected by ADVI was 13% (95% CI 10% to 17%; I2=81%) and 16% (95% CI 12% to 22%; I2=69%) with NCCT (p=0.29). sICH with ADVI was 4% (95% CI 3% to 7%; I2=73%) and 6% with NCCT/CTA (95% CI 4% to 8%; I2=6%, p=0.27). CONCLUSIONS Our study suggests that, in anterior circulation LVO, the rates of functional independence may be similar when patients are selected using ADVI or NCCT for EVT in the extended time window. A simplified triage protocol does not seem to increase mortality or sICH. PROTOCOL REGISTRATION NUMBER: (PROSPERO ID: CRD42021236092).
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Affiliation(s)
- Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aaron Rodriguez-Calienes
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
| | - Sandra S Chavez-Malpartida
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Cristian Morán-Mariños
- Unidad de Investigacion en Bibliometria, Universidad San Ignacio de Loyola, Lima, Peru
- Servicio de Neumologia, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Giancarlo Alvarado-Gamarra
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Departamento de Pediatria, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
- Departamento de Pediatria, Instituto de Investigación Nutricional, Lima, Peru
| | - Marco Malaga
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | - Alvaro Quincho-Lopez
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Wendy Hernadez-Fernandez
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Vicerrectorado de Investigacion, Unidad de Investigacion para la Generacion y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Carlos Alva-Diaz
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
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2
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Bala F, Kim BJ, Najm M, Thornton J, Fainardi E, Michel P, Alpay K, Herlihy D, Goyal M, Casetta I, Nannoni S, Ylikotila P, Power S, Saia V, Hegarty A, Pracucci G, Rautio R, Ademola A, Demchuk A, Mangiafico S, Boyle K, Hill MD, Toni D, Murphy S, Menon BK, Almekhlafi MA. Outcomes with Endovascular Treatment of Patients with M2 Segment MCA Occlusion in the Late Time Window. AJNR Am J Neuroradiol 2023; 44:447-452. [PMID: 36958801 PMCID: PMC10084904 DOI: 10.3174/ajnr.a7833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/23/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Randomized trials in the late window have demonstrated the efficacy and safety of endovascular thrombectomy in large-vessel occlusions. Patients with M2-segment MCA occlusions were excluded from these trials. We compared outcomes with endovascular thrombectomy in patients with M2-versus-M1 occlusions presenting 6-24 hours after symptom onset. MATERIALS AND METHODS Analyses were on pooled data from studies enrolling patients with stroke treated with endovascular thrombectomy 6-24 hours after symptom onset. We compared 90-day functional independence (mRS ≤ 2), mortality, symptomatic intracranial hemorrhage, and successful reperfusion (expanded TICI = 2b-3) between patients with M2 and M1 occlusions. The benefit of successful reperfusion was then assessed among patients with M2 occlusion. RESULTS Of 461 patients, 367 (79.6%) had M1 occlusions and 94 (20.4%) had M2 occlusions. Patients with M2 occlusions were older and had lower median baseline NIHSS scores. Patients with M2 occlusion were more likely to achieve 90-day functional independence than those with M1 occlusion (adjusted OR = 2.13; 95% CI, 1.25-3.65). There were no significant differences in the proportion of successful reperfusion (82.9% versus 81.1%) or mortality (11.2% versus 17.2%). Symptomatic intracranial hemorrhage risk was lower in patients with M2-versus-M1 occlusions (4.3% versus 12.2%, P = .03). Successful reperfusion was independently associated with functional independence among patients with M2 occlusions (adjusted OR = 2.84; 95% CI, 1.11-7.29). CONCLUSIONS In the late time window, patients with M2 occlusions treated with endovascular thrombectomy achieved better clinical outcomes, similar reperfusion, and lower symptomatic intracranial hemorrhage rates compared with patients with M1 occlusion. These results support the safety and benefit of endovascular thrombectomy in patients with M2 occlusions in the late window.
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Affiliation(s)
- F Bala
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Diagnostic and Interventional Neuroradiology Department (F.B.), University Hospital of Tours, Tours, France
| | - B J Kim
- Department of Neurology and Cerebrovascular Center (B.J.K.), Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - M Najm
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - J Thornton
- Neuroradiology Department (J.T., D.H., S.P.)
- Royal College of Surgeons in Ireland (J.T., A.H.), Dublin, Ireland
| | - E Fainardi
- Neuroradiology Unit (E.F.), Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - P Michel
- Stroke Center (P.M., S.N.), Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - K Alpay
- Department of Radiology (K.A., R.R.), Turku University Hospital, Turku, Finland
| | - D Herlihy
- Neuroradiology Department (J.T., D.H., S.P.)
| | - M Goyal
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - I Casetta
- Clinica Neurologica (I.C.), University of Ferrara, Ferrara, Italy
| | - S Nannoni
- Stroke Center (P.M., S.N.), Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - P Ylikotila
- Neurocenter (P.Y.), Turku University Hospital, University of Turku, Turku, Finland
| | - S Power
- Neuroradiology Department (J.T., D.H., S.P.)
| | - V Saia
- Stroke Unit (V.S.), Santa Corona Hospital, Pietra Ligure, Italy
| | - A Hegarty
- Royal College of Surgeons in Ireland (J.T., A.H.), Dublin, Ireland
| | - G Pracucci
- Stroke Unit (G.P.), Careggi University Hospital, Florence, Italy
| | - R Rautio
- Department of Radiology (K.A., R.R.), Turku University Hospital, Turku, Finland
| | - A Ademola
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - A Demchuk
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - S Mangiafico
- Interventional Neuroradiology Unit (S. Mangiafico), Institute for Hospitalization and Healthcare Neuromed, Pozzilli, Italy
| | - K Boyle
- Department of Geriatric and Stroke Medicine (K.B.), Beaumont Hospital, Dublin, Ireland
| | - M D Hill
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - D Toni
- Emergency Department (D.T.), Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - S Murphy
- Department of Geriatric and Stroke Medicine (S. Murphy), The Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine (S. Murphy), Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine (S. Murphy), University College Dublin, Dublin, Ireland
| | - B K Menon
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - M A Almekhlafi
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
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3
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López-Rueda A, Ibáñez Sanz L, Alonso de Leciñana M, de Araújo Martins-Romeo D, Vicente Bartulos A, Castellanos Rodrigo M, Oleaga Zufiria L. Recommendations on the use of computed tomography in the stroke code: Consensus document SENR, SERAU, GEECV-SEN, SERAM. RADIOLOGIA 2023; 65:180-191. [PMID: 37059583 DOI: 10.1016/j.rxeng.2022.11.006] [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: 09/17/2022] [Accepted: 11/18/2022] [Indexed: 03/31/2023]
Abstract
The Spanish Society of Emergency Radiology (SERAU), the Spanish Society of Neuroradiology (SENR), the Spanish Society of Neurology through its Cerebrovascular Diseases Study Group (GEECV-SEN) and the Spanish Society of Medical Radiology (SERAM) have met to draft this consensus document that will review the use of computed tomography in the stroke code patients, focusing on its indications, the technique for its correct acquisition and the possible interpretation mistakes.
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Affiliation(s)
- A López-Rueda
- Sección Radiología Vascular e Intervencionista, Hospital Clínic, Barcelona, Spain.
| | - L Ibáñez Sanz
- Radiología de Urgencias, Hospital 12 de Octubre, Madrid, Spain
| | - M Alonso de Leciñana
- Servicio de Neurología y Centro de Ictus, Instituto para la Investigación biomédica-Hospital Universitario la Paz (IdiPAZ), Universidad Autónoma de Madrid, Madrid, Spain
| | | | - A Vicente Bartulos
- Sección de Radiología de Urgencias, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Castellanos Rodrigo
- Servicio de Neurología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - L Oleaga Zufiria
- Sección Radiología Vascular e Intervencionista, Hospital Clínic, Barcelona, Spain
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4
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López-Rueda A, Ibáñez Sanz L, Alonso de Leciñana M, de Araújo Martins-Romeo D, Vicente Bartulos A, Castellanos Rodrigo M, Oleaga Zufiria L. Recomendaciones sobre el uso de la tomografía computarizada en el código ictus: Documento de consenso SENR, SERAU, GEECV-SEN, SERAM. RADIOLOGIA 2023. [DOI: 10.1016/j.rx.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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5
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Almekhlafi MA, Thornton J, Casetta I, Goyal M, Nannoni S, Herlihy D, Fainardi E, Power S, Saia V, Hegarty A, Pracucci G, Demchuk A, Mangiafico S, Boyle K, Michel P, Bala F, Gill R, Kuczynski A, Ademola A, Hill MD, Toni D, Murphy S, Kim BJ, Menon BK. Stroke imaging prior to thrombectomy in the late window: results from a pooled multicentre analysis. J Neurol Neurosurg Psychiatry 2022; 93:468-474. [PMID: 35086938 DOI: 10.1136/jnnp-2021-327959] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 12/30/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Collateral assessment using CT angiography is a promising modality for selecting patients for endovascular thrombectomy (EVT) in the late window (6-24 hours). The outcome of these patients compared with those selected using perfusion imaging is not clear. METHODS We pooled data from seven trials and registries of EVT-treated patients in the late-time window. Patients were classified according to the baseline imaging into collateral imaging alone (collateral cohort) and perfusion plus collateral imaging (perfusion cohort). The primary outcome was the proportion of patients achieving independent 90-day functional outcome (modified Rankin Scale 'mRS' 0-2). We used the propensity score-weighting method to balance important predictors between the cohorts. RESULTS In 608 patients, the median onset/last-known-well to emergency arrival time was 8.8 hours and 53.2% had wake-up strokes. Both cohorts had collateral imaging and 379 (62.3%) had perfusion imaging. Independent functional outcome was achieved in 43.1% overall: 168/379 patients (45.5%) in the perfusion cohort versus 94/214 (43.9%) in the collateral cohort (p=0.71). A logistic regression model adjusting for inverse-probability-weighting showed no difference in 90-day mRS score of 0-2 among the perfusion versus collateral cohorts (adjusted OR 1.05, 95% CI 0.69 to 1.59, p=0.83) or in a favourable shift in 90-day mRS (common adjusted OR 1.01, 95% CI 0.69 to 1.47, p=0.97). CONCLUSION This pooled analysis of late window EVT showed comparable functional outcomes in patients selected for EVT using collateral imaging alone compared with patients selected using perfusion and collateral imaging. PROSPERO REGISTRATION NUMBER CRD42020222003.
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Affiliation(s)
- Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences. Hotchkiss Brain Institute and O'Brien Institute for Public Health, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | - John Thornton
- Neuroradiology Department, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ilaria Casetta
- Clinica Neurologica, University of Ferrara, Ferrara, Italy
| | - Mayank Goyal
- Departments of Clinical Neurosciences, Radiology, and Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Darragh Herlihy
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Toscana, Italy
| | - Sarah Power
- Interventional Neuroradiology Service, Neuroradiology Department, Beaumont Hospital, Dublin, Leinster, Ireland
| | - Valentina Saia
- Neurology and Stroke Unit, Hospital Santa Corona, Pietra Ligure, Liguria, Italy
| | - Aidan Hegarty
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | | | - Andrew Demchuk
- Departments of Clinical Neurosciences, Radiology, and Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | | | - Karl Boyle
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Fouzi Bala
- Departments of Clinical Neurosciences, Radiology, and Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | - Rubina Gill
- Departments of Clinical Neurosciences, Radiology, and Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | - Andrea Kuczynski
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Ayolla Ademola
- Departments of Clinical Neurosciences, Radiology, and Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Departments of Clinical Neurosciences, Radiology, Community Health Sciences, and Medicine. Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | - Danilo Toni
- Department of Human Neuroscience; Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital, School of Medicine, Royal College of Surgeons in Ireland, University College Dublin, Dublin, Ireland
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Bundang-gu, Gyeonggi-do, Republic of Korea
| | - Bijoy K Menon
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences. Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
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Fladt J, d'Esterre CD, Joundi R, McDougall C, Gensicke H, Barber P. Acute stroke imaging selection for mechanical thrombectomy in the extended time window: is it time to go back to basics? A review of current evidence. J Neurol Neurosurg Psychiatry 2022; 93:238-245. [PMID: 35115388 DOI: 10.1136/jnnp-2021-328000] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022]
Abstract
Treatment with endovascular therapy in the extended time window for acute ischaemic stroke with large vessel occlusion involves stringent selection criteria based on the two landmark studies DAWN and DEFUSE3. Current protocols typically include the requirement of advanced perfusion imaging which may exclude a substantial proportion of patients from receiving a potentially effective therapy. Efforts to offer endovascular reperfusion therapies to all appropriate candidates may be facilitated by the use of simplified imaging selection paradigms with widely available basic imaging techniques, such as non-contrast CT and CT angiography. Currently available evidence from our literature review suggests that patients meeting simplified imaging selection criteria may benefit as much as those patients selected using advanced imaging techniques (CT perfusion or MRI) from endovascular therapy in the extended time window. A comprehensive understanding of the role of imaging in patient selection is critical to optimising access to endovascular therapy in the extended time window and improving outcomes in acute stroke. This article provides an overview on current developments and future directions in this emerging area.
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Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Christopher D d'Esterre
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Raed Joundi
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Connor McDougall
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Philip Barber
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Bala F, Casetta I, Nannoni S, Herlihy D, Goyal M, Fainardi E, Michel P, Thornton J, Power S, Saia V, Hegarty A, Pracucci G, Demchuk A, Mangiafico S, Boyle K, Hill MD, Toni D, Murphy S, Ademola A, Kim BJ, Menon BK, Almekhlafi MA. Sex-Related Differences in Outcomes After Endovascular Treatment of Patients With Late-Window Stroke. Stroke 2022; 53:311-318. [PMID: 34983244 DOI: 10.1161/strokeaha.121.037127] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Sex-related differences exist in many aspects of acute stroke and were mainly investigated in the early time window with conflicting results. However, data regarding sex disparities in late presenters are scarce. Therefore, we sought to investigate differences in outcomes between women and men treated with endovascular treatment in the late time window. METHODS Analyses were based on the SOLSTICE Consortium (Selection of Late-Window Stroke for Thrombectomy by Imaging Collateral Extent), which was an individual-patient level analysis of seven trials and registries. Baseline characteristics, 90-day functional independence (modified Rankin Scale score ≤2), mortality, and symptomatic intracranial hemorrhage were compared between women and men. Effect of sex on the association of age and successful reperfusion (final Thrombolysis in Cerebral Infarction 2b-3) with outcomes was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, time from onset to puncture, occlusion location, intravenous thrombolysis, and successful reperfusion, with interaction terms. RESULTS Among 608 patients treated with endovascular treatment, 50.5% were women. Women were older than men (median age of 72 versus 68 years, P=0.02) and had a lower prevalence of tandem occlusions (14.0% versus 22.9%, P=0.005). Workflow times were similar between sexes. Adjusted outcomes did not differ between women and men. Functional independence at 90 days was achieved by 127 out of 292 women (43.5%) and 135 out of 291 men (46.4%). Mortality at 90 days (54 [18.5%] versus 48 [16.5%]) and symptomatic intracranial hemorrhage (37 [13.3%] versus 33 [11.6%]) were similar between women and men. There was no sex-by-age interaction on functional outcomes. However, men had higher likelihood of mortality (Pinteraction=0.003) and symptomatic intracranial hemorrhage (Pinteraction=0.017) with advancing age. Sex did not influence the relation between successful reperfusion and outcomes. CONCLUSIONS In this multicenter analysis of late patients treated with endovascular treatment, sex was not associated with functional outcome. However, sex influenced the association between age and safety outcomes, with men experiencing worse outcomes with advancing age.
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Affiliation(s)
- Fouzi Bala
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.)
| | - Ilaria Casetta
- Clinica Neurologica, University of Ferrara, Italy (I.C.)
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (S.N., P.M.)
| | - Darragh Herlihy
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland. (D.H., J.T., S.P., A.H.)
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.)
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy (E.F.)
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (S.N., P.M.)
| | - John Thornton
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland. (D.H., J.T., S.P., A.H.).,Royal College of Surgeons in Ireland, Dublin, Ireland (J.T.)
| | - Sarah Power
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland. (D.H., J.T., S.P., A.H.)
| | - Valentina Saia
- Stroke Unit, Santa Corona Hospital, Pietra Ligure (SV), Italy (V.S.)
| | - Aidan Hegarty
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland. (D.H., J.T., S.P., A.H.)
| | | | - Andrew Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.)
| | | | - Karl Boyle
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland. (K.B.)
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.).,Department of Community Health Sciences, University of Calgary, Alberta, Canada. (M.D.H., A.A., B.K.M., M.A.A.)
| | - Danilo Toni
- Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy (D.T.)
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital; School of Medicine, Royal College of Surgeons in Ireland; School of Medicine, University College Dublin, Ireland (S.M.)
| | - Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, Alberta, Canada. (M.D.H., A.A., B.K.M., M.A.A.)
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea (B.J.K.)
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.).,Department of Community Health Sciences, University of Calgary, Alberta, Canada. (M.D.H., A.A., B.K.M., M.A.A.)
| | - Mohammed A Almekhlafi
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.).,Department of Community Health Sciences, University of Calgary, Alberta, Canada. (M.D.H., A.A., B.K.M., M.A.A.)
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8
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Bouslama M, Haussen DC, Rodrigues G, Barreira C, Frankel M, Nogueira RG. Novel selection paradigms for endovascular stroke treatment in the extended time window. J Neurol Neurosurg Psychiatry 2021; 92:1152-1157. [PMID: 34117100 DOI: 10.1136/jnnp-2020-325284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/31/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The optimal selection methodology for stroke thrombectomy beyond 6 hours remains to be established. METHODS Review of a prospectively collected database of thrombectomy patients with anterior circulation strokes, adequate CT perfusion (CTP) maps, National Institute of Health Stroke Scale (NIHSS)≥10 and presenting beyond 6 hours from January 2014 to October 2018. Patients were categorised according to five selection paradigms: DAWN clinical-core mismatch (DAWN-CCM): between age-adjusted NIHSS and CTP core, DEFUSE 3 perfusion imaging mismatch (DEFUSE-3-PIM): between CTP-derived perfusion defect (Tmax >6 s lesion) and ischaemic core volumes and three non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS)-based criteria: age-adjusted clinical-ASPECTS mismatch (aCAM): between age-adjusted NIHSS and ASPECTS, eloquence-adjusted clinical ASPECTS mismatch (eCAM): ASPECTS 6-10 and non-involvement of the right M6 and left M4 areas and standard clinical ASPECTS mismatch (sCAM): ASPECTS 6-10. RESULTS 310 patients underwent analysis. DEFUSE-3-PIM had the highest proportion of qualifying patients followed by sCAM, eCAM, aCAM and DAWN-CCM (93.5%, 92.6%, 90.6%, 90% and 84.5%, respectively). Patients meeting aCAM, eCAM, sCAM and DAWN-CCM criteria had higher rates of 90-day good outcome compared with their non-qualifying counterparts(43.2% vs 12%,p=0.002; 42.4% vs 17.4%, p=0.02; 42.4% vs 11.2%, p=0.009; and 43.7% vs 20.5%, p=0.007, respectively). There was no difference between patients meeting DEFUSE-3-PIM criteria versus not(40.8% vs 31.3%,p=0.45). In multivariate analysis, all selection modalities except for DEFUSE-3-PIM were independently associated with 90-day good outcome. CONCLUSIONS ASPECTS-based selection paradigms for late presenting and wake-up strokes ET have comparable proportions of qualifying patients and similar 90-day functional outcomes as DAWN-CCM and DEFUSE-3-PIM. They also might lead to better outcome discrimination. These could represent a potential alternative for centres where access to advanced imaging is limited.
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Affiliation(s)
- Mehdi Bouslama
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Diogo C Haussen
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Gabriel Rodrigues
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Clara Barreira
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Michael Frankel
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Raul G Nogueira
- Neurology, Emory University, Atlanta, Georgia, USA .,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
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9
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Lu J, Mei Q, Hou X, Manaenko A, Zhou L, Liebeskind DS, Zhang JH, Li Y, Hu Q. Imaging Acute Stroke: From One-Size-Fit-All to Biomarkers. Front Neurol 2021; 12:697779. [PMID: 34630278 PMCID: PMC8497192 DOI: 10.3389/fneur.2021.697779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/30/2021] [Indexed: 12/27/2022] Open
Abstract
In acute stroke management, time window has been rigidly used as a guide for decades and the reperfusion treatment is only available in the first few limited hours. Recently, imaging-based selection of patients has successfully expanded the treatment window out to 16 and even 24 h in the DEFUSE 3 and DAWN trials, respectively. Recent guidelines recommend the use of imaging techniques to guide therapeutic decision-making and expanded eligibility in acute ischemic stroke. A tissue window is proposed to replace the time window and serve as the surrogate marker for potentially salvageable tissue. This article reviews the evolution of time window, addresses the advantage of a tissue window in precision medicine for ischemic stroke, and discusses both the established and emerging techniques of neuroimaging and their roles in defining a tissue window. We also emphasize the metabolic imaging and molecular imaging of brain pathophysiology, and highlight its potential in patient selection and treatment response prediction in ischemic stroke.
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Affiliation(s)
- Jianfei Lu
- Central Laboratory, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiyong Mei
- Department of Neurosurgery, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Xianhua Hou
- Department of Neurology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Anatol Manaenko
- National Health Commission Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lili Zhou
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - David S Liebeskind
- Neurovascular Imaging Research Core and University of California Los Angeles Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - John H Zhang
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Yao Li
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Hu
- Central Laboratory, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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10
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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11
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Nannoni S, Kaesmacher J, Ricciardi F, Strambo D, Dunet V, Hajdu S, Saliou G, Mordasini P, Hakim A, Arnold M, Gralla J, Fischer U, Michel P. ASPECTS-based selection for late endovascular treatment: a retrospective two-site cohort study. Int J Stroke 2021; 17:434-443. [PMID: 33787411 DOI: 10.1177/17474930211009806] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The DAWN trial demonstrated the effectiveness of late endovascular treatment in acute ischemic stroke patients selected on the basis of a clinical-core mismatch. We explored in a real-world sample of endovascular treatment patients if a clinical-ASPECTS (Alberta Stroke Program Early CT Score) mismatch was associated with an outcome benefit after late endovascular treatment. METHODS We retrospectively analyzed all consecutive acute ischemic stroke patients admitted 6-24 h after last proof of good health in two stroke centers, with initial National Institutes of Health Stroke Scale (NIHSS) ≥10 and an internal carotid artery or M1 occlusion. We defined clinical-ASPECTS mismatch as NIHSS ≥ 10 and ASPECTS ≥ 7, or NIHSS ≥ 20 and ASPECTS ≥ 5. We assessed the interaction between the presence of the clinical-ASPECTS mismatch and late endovascular treatment using ordinal shift analysis of the three-month modified Rankin Scale and adjusting for multiple confounders. RESULTS The included 337 patients had a median age of 73 years (IQR = 61-82), admission NIHSS of 18 (15-22), and baseline ASPECTS of 7 (5-9). Out of 196 (58.2%) patients showing clinical-ASPECTS mismatch, 146 (74.5%) underwent late endovascular treatment. Among 141 (41.8%) mismatch negative patients, late endovascular treatment was performed in 72 (51.1%) patients. In the adjusted analysis, late endovascular treatment was significantly associated with a better outcome in the presence of clinical-ASPECTS mismatch (adjusted odd ratio, aOR = 2.83; 95% confidence interval, CI: 1.48-5.58) but not in its absence (aOR = 1.32; 95%CI: 0.61-2.84). The p-value for the interaction term between clinical-ASPECTS mismatch and late endovascular treatment was 0.073. CONCLUSIONS In our retrospective two-site analysis, late endovascular treatment seemed effective in the presence of a clinical-ASPECTS mismatch, but not in its absence. If confirmed in randomized trials, this finding could support the use of an ASPECTS-based selection for late endovascular treatment decisions, obviating the need for advanced imaging.
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Affiliation(s)
- Stefania Nannoni
- Stroke Center, Neurology Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland.,Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Federico Ricciardi
- Stroke Center, Neurology Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, 30635Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - Steven Hajdu
- Department of Diagnostic and Interventional Radiology, 30635Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - Guillaume Saliou
- Department of Diagnostic and Interventional Radiology, 30635Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Arsany Hakim
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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12
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Dekker L, Venema E, Pirson FAV, Majoie CBLM, Emmer BJ, Jansen IGH, Mulder MJHL, Lemmens R, Goldhoorn RJB, Wermer MJH, Boiten J, Lycklama À Nijeholt GJ, Roos YBWEM, van Es ACGM, Lingsma HF, Dippel DWJ, van Zwam WH, van Oostenbrugge RJ, van den Wijngaard IR. Endovascular treatment in anterior circulation stroke beyond 6.5 hours after onset or time last seen well: results from the MR CLEAN Registry. Stroke Vasc Neurol 2021; 6:572-580. [PMID: 33827915 PMCID: PMC8717786 DOI: 10.1136/svn-2020-000803] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/03/2021] [Accepted: 03/10/2021] [Indexed: 12/02/2022] Open
Abstract
Background Randomised controlled trials with perfusion selection have shown benefit of endovascular treatment (EVT) for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well. However, outcomes after EVT in these late window patients without perfusion imaging are largely unknown. We assessed their characteristics and outcomes in routine clinical practice. Methods The Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective, multicentre study in the Netherlands, included patients with an anterior circulation occlusion who underwent EVT between 2014 and 2017. CT perfusion was no standard imaging modality. We used adjusted ordinal logistic regression analysis to compare patients treated within versus beyond 6.5 hours after propensity score matching on age, prestroke modified Rankin Scale (mRS), National Institutes of Health Stroke Scale, Alberta Stroke Programme Early CT Score (ASPECTS), collateral status, location of occlusion and treatment with intravenous thrombolysis. Outcomes included 3-month mRS score, functional independence (defined as mRS 0–2), and death. Results Of 3264 patients who underwent EVT, 106 (3.2%) were treated beyond 6.5 hours (median 8.5, IQR 6.9–10.6), of whom 93 (87.7%) had unknown time of stroke onset. CT perfusion was not performed in 87/106 (80.2%) late window patients. Late window patients were younger (mean 67 vs 70 years, p<0.04) and had slightly lower ASPECTS (median 8 vs 9, p<0.01), but better collateral status (collateral score 2–3: 68.3% vs 57.7%, p=0.03). No differences were observed in proportions of functional independence (43.3% vs 40.5%, p=0.57) or death (24.0% vs 28.9%, p=0.28). After matching, outcomes remained similar (adjusted common OR for 1 point improvement in mRS 1.04, 95% CI 0.56 to 1.93). Conclusions Without the use of CT perfusion selection criteria, EVT in the 6.5–24-hour time window was not associated with poorer outcome in selected patients with favourable clinical and CT/CT angiography characteristics. randomised controlled trials with lenient inclusion criteria are needed to identify more patients who can benefit from EVT in the late window.
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Affiliation(s)
- Luuk Dekker
- Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Esmee Venema
- Neurology, Erasmus MC, Rotterdam, The Netherlands .,Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - F Anne V Pirson
- Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Bart J Emmer
- Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Ivo G H Jansen
- Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | | | - Robin Lemmens
- Neurology, University Hospitals Leuven, Leuven, Belgium.,Neurosciences, Experimental Neurology and Leuven Brain Institute, University of Leuven, Leuven, Belgium.,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
| | | | | | - Jelis Boiten
- Neurology, Haaglanden Medical Centre, Den Haag, The Netherlands
| | | | - Yvo B W E M Roos
- Neurology, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Adriaan C G M van Es
- Radiology, Haaglanden Medical Centre, Den Haag, The Netherlands.,Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Wim H van Zwam
- Radiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Ido R van den Wijngaard
- Neurology, Leiden University Medical Centre, Leiden, The Netherlands.,Neurology, Haaglanden Medical Centre, Den Haag, The Netherlands
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13
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Delgado Acosta F, Jiménez Gómez E, Bravo Rey I, Bolivar A, Valverde Moyano R, Oteros Fernández R. Endovascular stroke treatment after 6-24 hours only needs non-contrast CT. Acta Neurol Scand 2021; 143:171-177. [PMID: 32969024 DOI: 10.1111/ane.13348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/21/2020] [Accepted: 09/10/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Imaging selected patients with proximal anterior circulation stroke who demonstrate limited infarct may benefit from endovascular treatment beyond conventional time limits. Our aim was to evaluate the results of the EVT group series arriving between 6 and 24 hours from the onset of symptoms with (ASPECTS) ≥7 to our hospital (with 24/7 interventional neuroradiology) comparing them with those obtained in our prospectively registered series arriving between 0 and 6 hours. MATERIALS AND METHODS The inclusion criteria were ≥18 years, an interval between stroke and endovascular treatment of 6-24 hours, prestroke score mRS 0-2, no intracranial haemorrhage, (NIHSS) scale 8-22 and infarct evaluated by CT scan ≥7 in ASPECTS scale. Data, including patient demographics, neuroimaging findings, procedural details, recanalization rates and 90-day mRS, were collected. RESULTS Twelve of the 14 (85.71%) endovascular group patients who came to our centre between 6 and 24 hours had good outcomes at 90 days. To confirm our findings, we evaluated patients treated at our centre who met the selection criteria from January 2017 to September 2019. In this period, 382 patients with large vessel occlusion were treated endovascularly. 56 patients met all the criteria for inclusion and exclusion for our study. 31 of these 56 patients (56.36%) obtained a (mRS) scale ≤2 at three months. There was no significant difference (P = 0.063). CONCLUSION In circumstances of difficult access to MRI or CT perfusion, a computed tomography of ASPECTS ≥7 is sufficient to indicate endovascular treatment in a stroke of known onset between 6 and 24 hours.
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14
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Bouslama M, Ravindran K, Harston G, Rodrigues GM, Pisani L, Haussen DC, Frankel MR, Nogueira RG. Noncontrast Computed Tomography e-Stroke Infarct Volume Is Similar to RAPID Computed Tomography Perfusion in Estimating Postreperfusion Infarct Volumes. Stroke 2021; 52:634-641. [PMID: 33430633 DOI: 10.1161/strokeaha.120.031651] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The e-Stroke Suite software (Brainomix, Oxford, United Kingdom) is a tool designed for the automated quantification of The Alberta Stroke Program Early CT Score and ischemic core volumes on noncontrast computed tomography (NCCT). We sought to compare the prediction of postreperfusion infarct volumes and the clinical outcomes across NCCT e-Stroke software versus RAPID (IschemaView, Menlo Park, CA) computed tomography perfusion measurements. METHODS All consecutive patients with anterior circulation large vessel occlusion stroke presenting at a tertiary care center between September 2010 and November 2018 who had available baseline infarct volumes on both NCCT e-Stroke Suite software and RAPID CTP as well as final infarct volume (FIV) measurements and achieved complete reperfusion (modified Thrombolysis in Cerebral Infarction scale 2c-3) post-thrombectomy were included. The associations between estimated baseline ischemic core volumes and FIV as well as 90-day functional outcomes were assessed. RESULTS Four hundred seventy-nine patients met inclusion criteria. Median age was 64 years (55-75), median e-Stroke and computed tomography perfusion ischemic core volumes were 38.4 (21.8-58) and 5 (0-17.7) mL, respectively, whereas median FIV was 22.2 (9.1-56.2) mL. The correlation between e-Stroke and CTP ischemic core volumes was moderate (R=0.44; P<0.001). Similarly, moderate correlations were observed between e-Stroke software ischemic core and FIV (R=0.52; P<0.001) and CTP core and FIV (R=0.43; P<0.001). Subgroup analysis showed that e-Stroke software and CTP performance was similar in the early and late (>6 hours) treatment windows. Multivariate analysis showed that both e-Stroke software NCCT baseline ischemic core volume (adjusted odds ratio, 0.98 [95% CI, 0.97-0.99]) and RAPID CTP ischemic core volume (adjusted odds ratio, 0.98 [95% CI, 0.97-0.99]) were independently and comparably associated with good outcome (modified Rankin Scale score of 0-2) at 90 days. CONCLUSIONS NCCT e-Stroke Suite software performed similarly to RAPID CTP in assessing postreperfusion FIV and functional outcomes for both early- and late-presenting patients. NCCT e-Stroke volumes seems to represent a viable alternative in centers where access to advanced imaging is limited. Moreover, the future development of fusion maps of NCCT and CTP ischemic core estimates may improve upon the current performance of these tools as applied in isolation.
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Affiliation(s)
- Mehdi Bouslama
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (M.B., K.R., G.M.R., L.P., D.C.H., M.R.F., R.G.N.)
| | - Krishnan Ravindran
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (M.B., K.R., G.M.R., L.P., D.C.H., M.R.F., R.G.N.)
| | - George Harston
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, United Kingdom (G.H.)
| | - Gabriel M Rodrigues
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (M.B., K.R., G.M.R., L.P., D.C.H., M.R.F., R.G.N.)
| | - Leonardo Pisani
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (M.B., K.R., G.M.R., L.P., D.C.H., M.R.F., R.G.N.)
| | - Diogo C Haussen
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (M.B., K.R., G.M.R., L.P., D.C.H., M.R.F., R.G.N.)
| | - Michael R Frankel
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (M.B., K.R., G.M.R., L.P., D.C.H., M.R.F., R.G.N.)
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (M.B., K.R., G.M.R., L.P., D.C.H., M.R.F., R.G.N.)
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15
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Little PV, Kraft SE, Chireh A, Damberg P, Holmin S. Oxygen metabolism MRI - A comparison with perfusion imaging in a rat model of MCA branch occlusion and reperfusion. J Cereb Blood Flow Metab 2020; 40:2315-2327. [PMID: 31842668 PMCID: PMC7585917 DOI: 10.1177/0271678x19892271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The penumbra is sustained by an increased extraction of oxygen (OEF) from blood to brain tissue. Metabolic imaging may improve penumbra specificity when examining stroke patients with wake-up stroke and a long time between admission and symptom onset. We used MRI to examine OEF, and compared the volume of regions with elevated OEF to the volume of regions with perfusion deficit in a M2 occlusion model (M2CAO) with preserved collateral blood flow. OEF was calculated from BOLD MRI examining tissue R2', with ASL perfusion imaging employed to determine cerebral blood flows (CBF) and volumes. Diffusion imaging was used to identify the ischemic core (IC). Examinations were performed during and after transient M2CAO in rats. The IC-OEF mismatch was significantly smaller than the IC-CBF mismatch during M2CAO. The penumbra OEF was significantly increased during M2CAO, and decreased significantly after reperfusion. The IC-OEF mismatch may provide increased penumbra specificity compared to IC-CBF mismatch regimens. Results strongly indicate the potential of metabolic MRI for thrombectomy patient selection in cases with a long time from symptom onset to admission. Results demonstrate the effectiveness of reperfusion in alleviating metabolic disturbances in ischemic regions, emphasizing fast treatment to achieve significant neurological recovery in stroke patients.
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Affiliation(s)
- Philip V Little
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, BioClinicum, Karolinska University Hospital, Stockholm, Sweden
| | - Sandra E Kraft
- Karolinska Experimental Research and Imaging Center (KERIC), Karolinska University Hospital-Solna, Stockholm, Sweden
| | - Arvin Chireh
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, BioClinicum, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Damberg
- Karolinska Experimental Research and Imaging Center (KERIC), Karolinska University Hospital-Solna, Stockholm, Sweden
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, BioClinicum, Karolinska University Hospital, Stockholm, Sweden
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16
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Alexandre AM, Pedicelli A, Valente I, Scarcia L, Giubbolini F, D'Argento F, Lozupone E, Distefano M, Pilato F, Colosimo C. May endovascular thrombectomy without CT perfusion improve clinical outcome? Clin Neurol Neurosurg 2020; 198:106207. [PMID: 32950754 DOI: 10.1016/j.clineuro.2020.106207] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion. The aim of our study is to evaluate results of endovascular thrombectomy in large intracranial vessel occlusion without perfusion CT patient selection. METHODS we reviewed our prospectively collected endovascular databases for patients with an acute stroke from March 2016 to October 2018, treated after 6 h from stroke onset, without perfusion CT selection. Baseline characteristics, procedural data, and outcomes were evaluated. A good outcome was defined as a 90-day modified Rankin Scale score of 0-2. The association between clinical and procedural parameters and functional outcome was assessed. RESULTS out of 212 patients 55 were treated after 6 h from stroke onset, 49 of which for an anterior circulation occlusion. 18/49 were functional independent at 90 days (mRS 0-2), Successful recanalization (mTICI 2b to 3) was achieved in 38/49 patients (77 %). Multivariate logistic regression indicated that a low baseline NIHSS was associated with favorable outcome (OR 0.66, 95 % CI 0.52-0.83, p-value 0.001). CONCLUSIONS in our retrospective analysis, baseline NIHSS is the only parameter that can predict good outcome (90-days mRS 0-2). We confirm data from recent papers assessing that perfusion CT can provide a better patients' selection compared to mCTA for large vessels occlusion treated beyond six hours from symptom onset.
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Affiliation(s)
- Andrea M Alexandre
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Roma, Italy.
| | - Alessandro Pedicelli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Roma, Italy.
| | - Iacopo Valente
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Roma, Italy.
| | - Luca Scarcia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Roma, Italy.
| | - Francesca Giubbolini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Roma, Italy.
| | - Francesco D'Argento
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Roma, Italy.
| | - Emilio Lozupone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Roma, Italy.
| | - Marisa Distefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, Roma, Italy.
| | - Fabio Pilato
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, Roma, Italy.
| | - Cesare Colosimo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologica ed ematologia, Roma, Italy; Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy.
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17
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Savello AV, Vozniuk IA, Svistov DV, Babichev KN, Kandyba DV, Shenderov SV, Vlasenko SV, Shloydo EA, Kachesov EU, Saraev GB, Sergeeva TV, Esipovich ID, Zubarev DD, Kharitonova TV. [Retrospective analysis of endovascular thrombectomy in anterior cerebral circulation out of 6-hours «therapeutic window» in regional vascular centers of Saint-Petersburg]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:50-55. [PMID: 32790976 DOI: 10.17116/jnevro202012007150] [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: 11/17/2022]
Abstract
OBJECTIVE Based on a retrospective analysis, to evaluate technical results and functional outcomes at discharge after endovascular thrombectomy (EVT) in anterior circulation out of 6-hours «therapeutic window» in patients with stroke. MATERIAL AND METHODS The retrospective analysis of EVT in 594 acute stroke patients (303 male, 291 female, median age 69 years) with the anterior circulation large vessel occlusion was performed. EVT was carried out before 6 hrs in 550, later in 44 patients. Time to artery puncture was defined as a cut point. Patients were included in the study if they met the criterion for 0-6 hours «therapeutic window». RESULTS No significant differences in functional outcomes at discharge assessed with the Rankin scale (mRs 0-2 29.8% and 20.5% p<0.19; mRs 3-5 38.7% and 38.6% p<0.99; mRs 6 31.5% and 40.9% p<0.2) and the rates of intracranial haemorrhage, haemorrhagic transformation and symptomatic haemorrhagic transformation (4% and 0% p<0.17; 20.9% and 29.5% p<0.49; 10.1% and 11.4% p<0.78) were observed in patients exposed to EVT before 6 hrs and later. CONCLUSION EVT in anterior circulation stroke over 6 hrs «therapeutic window» based on the criterion for 0-6 hrs provides comparable functional outcomes at discharge without the increase in the frequency of intracranial haemorrhages, haemorrhagic and symptomatic haemorrhagic transformations.
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Affiliation(s)
- A V Savello
- Kirov Medical Military Academy, St. Petersburg, Russia.,Almazov National Medical Resaerch Center, St.Petersburg, Russia
| | - I A Vozniuk
- Kirov Medical Military Academy, St. Petersburg, Russia.,Dzhanelidze Saint-Petersburg Research Institute of Emergency Medicine, St.Petersburg Russi, Dzhanelidze Saint-Petersburg Research Institute of Emergency Medicine, St.Petersburg Russia
| | - D V Svistov
- Kirov Medical Military Academy, St. Petersburg, Russia
| | - K N Babichev
- Kirov Medical Military Academy, St. Petersburg, Russia
| | - D V Kandyba
- Dzhanelidze Saint-Petersburg Research Institute of Emergency Medicine, St.Petersburg Russi, Dzhanelidze Saint-Petersburg Research Institute of Emergency Medicine, St.Petersburg Russia
| | - S V Shenderov
- City Multi-Field Hospital No. 26, St. Petersburg, Russia
| | - S V Vlasenko
- City Multi-Field Hospital No. 40, St. Petersburg, Russia
| | - E A Shloydo
- City Multi-Field Hospital No. 2, St. Petersburg, Sestroretsk, Russia
| | - E U Kachesov
- City Multi-Field Hospital «Alexandrovskaya bolnitsa», St. Petersburg, Russia
| | - G B Saraev
- City Multi-Field Hospital «Elizavetinskaya bolnitsa», St. Petersburg, Russia
| | - T V Sergeeva
- City Multi-Field Hospital «Elizavetinskaya bolnitsa», St. Petersburg, Russia
| | - I D Esipovich
- Almazov National Medical Resaerch Center, St.Petersburg, Russia
| | - D D Zubarev
- Almazov National Medical Resaerch Center, St.Petersburg, Russia
| | - T V Kharitonova
- Dzhanelidze Saint-Petersburg Research Institute of Emergency Medicine, St.Petersburg Russi, Dzhanelidze Saint-Petersburg Research Institute of Emergency Medicine, St.Petersburg Russia
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18
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Kim BJ, Menon BK, Kim JY, Shin DW, Baik SH, Jung C, Han MK, Demchuk A, Bae HJ. Endovascular Treatment After Stroke Due to Large Vessel Occlusion for Patients Presenting Very Late From Time Last Known Well. JAMA Neurol 2020; 78:2769023. [PMID: 32777014 PMCID: PMC7418043 DOI: 10.1001/jamaneurol.2020.2804] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Endovascular treatment (EVT) after ischemic stroke due to emergent large vessel occlusion is usually constrained by a specific window of less than 16 to 24 hours from the time the patient was last known well (LKW). Patients with slow progression and tenacious collateral circulation may persist beyond 16 hours. OBJECTIVES To estimate the prevalence of salvageable tissues 16 hours or more from LKW after ischemic stroke due to emergent large vessel occlusion and investigate the effectiveness of EVT in delayed large vessel occlusion. DESIGN, SETTING AND PARTICIPANTS In this case-control study, from a total of 8032 patients with stroke or transient ischemic attack who were admitted between January 1, 2012, and December 31, 2018, to a single referral university hospital, 150 patients were retrospectively identified who had an acute ischemic stroke with internal carotid artery or middle cerebral artery occlusion, had a baseline National Institutes of Health Stroke Scale score of 6 or more, and arrived 16 hours or more from time LKW. The decision for EVT was made by a treating physician according to the institutional protocol. MAIN OUTCOMES AND MEASURES Baseline ischemic core, collateral circulation status, and computed tomographic or magnetic resonance perfusion parameters were retrospectively quantified. Follow-up images, evaluated a median of 93 hours (interquartile range, 66-120 hours) after arrival, were used to assess the final infarct and hemorrhagic transformation. The main outcome was the modified Rankin Scale score at 90 days. RESULTS For 150 patients (81 men [54%]; mean [SD] age at onset, 70.1 [13.0] years; median National Institutes of Health Stroke Scale score, 12 [interquartile range, 8-18]), the median ischemic core volume was 11.5 mL (interquartile range, 0-39.1 mL), the median penumbra volume (>6 seconds) was 55.0 mL (interquartile range, 15-128 mL), and the median mismatch ratio was 4.0 (interquartile range, 0.9-18.3). By the imaging inclusion criteria for EVT trials, there were 50 DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-up and Late Presenting Strokes Undergoing Neurointervention With Trevo)-eligible patients (33%), 58 DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke)-eligible patients (39%), and 57 ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times)-eligible patients (38%). Endovascular treatment was performed for 24 patients (16%). In propensity score-matched analyses, EVT was associated with better odds of a 90-day modified Rankin Scale score of 0 to 2 (adjusted odds ratio, 11.08 [95% CI, 1.88-108.60]) and a 90-day modified Rankin Scale score shift (common adjusted odds ratio, 5.17 [95% CI, 1.80-15.62]). Type 2 parenchymal hemorrhage was seen in 3 of 24 patients (13%) who received EVT and in 4 of 126 patients (3%) who received medical management (adjusted odds ratio, 4.06 [95% CI, 0.63-26.30]). In a subgroup of 109 patients who were 24 hours from time LKW, EVT was associated with a favorable mRS shift (common adjusted odds ratio, 10.54 [95% CI, 2.18-59.34]). CONCLUSIONS AND RELEVANCE This study suggests that patients with anterior circulation large vessel occlusion presenting very late (>16 hours to 10 days) from the time they were LKW may benefit from EVT.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Bijoy K. Menon
- Department of Clinical Neurosciences and Radiology, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Dong-Woo Shin
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Andrew Demchuk
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
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19
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Non-Contrast CT and CT-Angiogram for Late Window Ischemic Stroke Treatment Selection. Can J Neurol Sci 2020; 47:309-313. [PMID: 31928557 DOI: 10.1017/cjn.2020.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The benefit of late window endovascular treatment (EVT) for anterior circulation ischemic stroke has been demonstrated using perfusion-based neuroimaging. We evaluated whether non-contrast CT (NCCT) and CT-angiogram (CTA) alone can select late-presenting patients for EVT. METHODS We performed a retrospective comparison of all patients undergoing EVT at a single comprehensive stroke center from January 2016 to April 2017. Patients planned for EVT were divided into early (<6 hours from onset) and late (≥6 hours from onset or last time seen normal) window groups. Incidence of symptomatic hemorrhagic transformations (sHTs) at 24 hours and 3-month modified Rankin scores (mRSs) were compared. RESULTS During the study period, 204 (82%) patients underwent EVT in the early and 44 (18%) in the late window. Median (interquartile range) NIH Stroke Scale Score was similar between groups (early: 18 [15-23] vs. late: 17 [13-21]), as were median ASPECT scores (early: 9 [8-10] vs. late: 9 [7-9]). In the late window, 42 (95%) strokes were of unknown onset. Similar proportions of sHT occurred at 24 hours (early: 12 [6%] vs. late: 4 [9%], p = 0.43). At 3 months, the proportion of patients achieving functional independence (mRS 0-2) were comparable in the early (80/192 [42%]) and late (16/41 [39%]) windows (p = 0.76). CONCLUSION NCCT- and CTA-based patient selection led to similar functional independence outcomes and low proportions of sHT in the early and late windows. In centers without access to perfusion-based neuroimaging, this pragmatic approach could be safe, particularly for strokes of unknown onset.
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20
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Almekhlafi MA, Kunz WG, McTaggart RA, Jayaraman MV, Najm M, Ahn SH, Fainardi E, Rubiera M, Khaw AV, Zini A, Hill MD, Demchuk AM, Goyal M, Menon BK. Imaging Triage of Patients with Late-Window (6-24 Hours) Acute Ischemic Stroke: A Comparative Study Using Multiphase CT Angiography versus CT Perfusion. AJNR Am J Neuroradiol 2019; 41:129-133. [PMID: 31806593 DOI: 10.3174/ajnr.a6327] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The role of collateral imaging in selecting patients for endovascular thrombectomy beyond 6 hours from onset has not been established. To assess the comparative utility of collateral imaging using multiphase CTA in selecting late window patients for EVT. MATERIALS AND METHODS We used data from a prospective multicenter observational study in which all patients underwent imaging with multiphase CT angiography as well as CTP. Two blinded reviewers evaluated patients' eligibility for endovascular thrombectomy using published collateral imaging (multiphase CTA) criteria compared with CTP using the selection criteria of the Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention with Trevo (DAWN) and Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE-3) trials. CTP images were processed using automated commercial software. The outcomes of patients eligible for endovascular thrombectomy according to multiphase CTA, DAWN, or DEFUSE-3 criteria were compared using multivariable logistic regression modeling. Model characteristics were compared using the C-statistic for the receiver operating characteristic curve, the Akaike information criterion, and the Bayesian information criterion. RESULTS Eighty-six patients presented beyond 6 hours from onset/last known well (median, 9.6 hours; interquartile range, 4.1 hours). Thirty-five patients (40.7%) received endovascular thrombectomy, of whom good functional outcome (90-day mRS, 0-2) was achieved in 16/35 (47%). Collateral-based imaging paradigms significantly modified the treatment effect of endovascular thrombectomy on 90-day mRS 0-2 (P interaction = .007). The multiphase CTA-based regression model best fit the data for the 90-day outcome (C-statistic, 0.86; 95% CI, 0.77-0.94) and was associated with the least information loss (Akaike information criterion, 95.7; Bayesian information criterion, 114.9) compared with CTP-based models. CONCLUSIONS The collateral-based imaging paradigm using multiphase CTA compares well with CTP in selecting patients for endovascular thrombectomy in the late time window.
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Affiliation(s)
- M A Almekhlafi
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.)
| | - W G Kunz
- Department of Radiology (W.G.K.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - R A McTaggart
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - M V Jayaraman
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - M Najm
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.)
| | - S H Ahn
- Department of Neurology (S.H.A.), Chosun University School of Medicine, Gwang Ju, South Korea
| | - E Fainardi
- Department of Neurosciences and Rehabilitation (E.F.), University Hospital, Ferrara, Italy
| | - M Rubiera
- Department of Neurology (M.R.), Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, Barcelona, Spain
| | - A V Khaw
- Department of Clinical Neurosciences (A.V.K.), University of Western Ontario, London, Ontario, Canada
| | - A Zini
- Department of Neurology and Stroke Center (A.Z.), Istituto Di Ricovero e Cura a Carattere Scientifico Istituto di Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - M D Hill
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.).,Department of Medicine (M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.)
| | - M Goyal
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.)
| | - B K Menon
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.) .,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.)
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Adams NC, Griffin E, Motyer R, Farrell T, Carmody E, O'Shea A, Murphy B, O'Hare A, Looby S, Power S, Brennan P, Doyle KM, Thornton J. Review of external referrals to a regional stroke centre: it is not just about thrombectomy. Clin Radiol 2019; 74:950-955. [PMID: 31521325 DOI: 10.1016/j.crad.2019.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 07/26/2019] [Indexed: 02/02/2023]
Abstract
AIMS To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO). MATERIALS AND METHODS Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not. RESULTS Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142). CONCLUSION These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.
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Affiliation(s)
- N C Adams
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland.
| | - E Griffin
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - R Motyer
- Department of Radiology, Tallaght Hospital, Tallaght, Dublin 24, Ireland
| | - T Farrell
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - E Carmody
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - A O'Shea
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - B Murphy
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - A O'Hare
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - S Looby
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - S Power
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - P Brennan
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - K M Doyle
- Department of Physiology, School of Medicine, National University of Ireland, Galway, Ireland
| | - J Thornton
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland; Honorary Clinical Associate Professor, Royal College of Surgeons, 123 St Stephens Green, Dublin, Ireland
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22
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Meinel TR, Kaesmacher J, Mordasini P, Mosimann PJ, Jung S, Arnold M, Heldner MR, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Pereira VM, Gralla J, Fischer U. Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry. Ther Adv Neurol Disord 2019; 12:1756286419835708. [PMID: 30944585 PMCID: PMC6437320 DOI: 10.1177/1756286419835708] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/03/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE In acute ischaemic stroke (AIS) of the anterior circulation (AC) treated with mechanical thrombectomy (MT), data point to a decline of treatment effect with increasing time from symptom onset to treatment. However, the magnitude of the decline will depend on the clinical setting and imaging selection used. The aims of this study were (1) to evaluate the clinical effect of time to reperfusion (TTR); and (2) to assess the safety and technical efficacy of MT according to strata of TTR. METHODS Using the retrospective multicentre BEYOND-SWIFT registry data (ClinicalTrials.gov identifier: NCT03496064), we compared safety and efficacy of MT in 1461 patients between TTR strata of 0-180 min (n = 192), 180-360 min (n = 876) and >360 min (n = 393). Clinical effect of TTR was evaluated using multivariable logistic regression analyses adjusting for pre-specified confounders [adjusted odds ratios (aOR) and 95% confidence intervals (95% CI)]. Primary outcome was good functional outcome (modified Rankin Scale: mRS 0-2) at day 90. RESULTS Every hour delay in TTR was a significant factor related to mRS 0-2 (aOR 0.933, 95% CI 0.887-0.981) with an estimated 1.5% decreased probability of good functional outcome per hour delay of reperfusion, and mRS 0-1 (aOR 0.929, 95% CI 0.877-0.985). Patients with late TTR had lower rates of successful and excellent reperfusion, higher complication rates and number of passes. CONCLUSIONS TTR is an independent factor related to long-term functional outcome. With increasing TTR, interventional procedures become technically less effective. Efforts should be made to shorten TTR through optimized prehospital and in-hospital pathways.
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Affiliation(s)
- Thomas Raphael Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pascal J. Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam Rachel Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Lausanne, Switzerland
| | - Steven D. Hajdu
- Department of Radiology, CHUV Lausanne, Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Laurent Pierot
- Department of Neurology, Toronto Western Hospital, Toronto, Canada
| | | | - Joanna Schaafsma
- Department of Neurology, Toronto Western Hospital, Toronto, Canada
| | | | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, CH-3010, Switzerland
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Santos T, Carvalho A, Cunha AA, Rodrigues M, Gregório T, Paredes L, Costa H, Roriz JM, Pinho J, Veloso M, Castro S, Barros P, Ribeiro M. NCCT and CTA-based imaging protocol for endovascular treatment selection in late presenting or wake-up strokes. J Neurointerv Surg 2018; 11:200-203. [DOI: 10.1136/neurintsurg-2018-014051] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/07/2018] [Accepted: 07/10/2018] [Indexed: 11/04/2022]
Abstract
IntroductionRecently, the benefit of selecting patients for endovascular treatment (EVT) beyond the 6-hour time window using a tissue-based approach was demonstrated in two randomized trials. The optimal imaging protocol for selecting patients is under debate, and it is still unknown if a simpler and faster protocol may adequately select patients with wake-up stroke (WUS) and late-presenting stroke (LPS) for EVT.ObjectiveTo compare outcomes of patients submitted to EVT presenting within 6 hours of symptom onset or 6–24 hours after last seen well, selected using non-contrast computed tomography (NCCT) and CT angiography (CTA).MethodsAn observational study was performed, which included consecutive patients with anterior circulation ischemic stroke with large vessel occlusion treated with EVT. Patients presenting within 6 hours were treated if their NIH Stroke Scale (NIHSS) score was ≥6 and Alberta Stroke Program Early CT score (ASPECTS) was ≥6, while patients presenting with WUS or 6–24 hours after last seen well (WUS/LPS) were treated if their NIHSSscore was ≥12 and ASPECTS was ≥7.Results249 patients were included, 63 of whom were in the WUS/LPS group. Baseline characteristics were similar between groups, except for longer symptom-recanalization time, lower admission NIHSS (16 vs 17, P=0.038), more frequent tandem occlusions (25.4% vs 11.8%, P=0.010), and large artery atherosclerosis etiology (22.2% vs 11.8%, P=0.043) in the WUS/LPS group. No differences in symptomatic intracranial hemorrhage, peri-procedural complications or mortality were found between groups. Three-month functional independence was similar in both groups (65.1% in WUS/LPS vs 57.0% in ≤6 hours, P=0.259) and no differences were found after adjustment for confounders.ConclusionsThis real-world observational study suggests that EVT may be safe and effective in patients with WUS and LPS selected using clinical-core mismatch (high NIHSS/high ASPECTS in NCCT).
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