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Diestro JDB, Omar AT, Zhang YQ, Kishibe T, Mastrolonardo A, Lannon MM, Ignacio K, Pimenta Ribeiro Pontes Almeida E, Malvea A, Diouf A, Sharma AV, Yang Q, Qiu Z, Almekhlafi MA, Nguyen TN, Zafar A, Pereira VM, Spears J, Marotta TR, Farrokhyar F, Sharma S. Perfusion vs non-perfusion computed tomography imaging in the late window of emergent large vessel ischemic stroke: A systematic review and meta-analysis. PLoS One 2024; 19:e0294127. [PMID: 38166040 PMCID: PMC10760723 DOI: 10.1371/journal.pone.0294127] [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: 09/01/2023] [Accepted: 10/25/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Guidelines recommend the treatment of emergent large vessel ischemic stroke (ELVIS) patients presenting beyond 6 hours of last known well time with endovascular thrombectomy (EVT) based on perfusion computed tomography (CT) neuroimaging. We compared the outcomes (long-term good clinical outcomes, symptomatic intracranial hemorrhage (sICH), and mortality) of ELVIS patients according to the type of CT neuroimaging they underwent. METHODS We searched the following databases: Medline, Embase, CENTRAL, and Scopus from January 1, 2015, to June 14, 2023. We included studies of late-presenting ELVIS patients undergoing EVT that had with data for non-perfusion and perfusion CT neuroimaging. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were pooled using a random effects model. RESULTS We found 7 observational cohorts. Non-perfusion versus perfusion CT was not statistically significantly different for both long-term clinical (n = 3,224; RR: 0.96; 95% CI 0.86 to 1.06; I2 = 18%) and sICH (n = 3,724; RR: 1.08 95% CI 0.60 to 1.94; I2 = 76%). Perfusion CT had less mortality (n = 3874; RR: 1.22; 95% CI 1.07 to 1.40; I2 = 0%). The certainty of these findings is very low because of limitations in the risk of bias, indirectness, and imprecision domains of the Grading of Recommendations, Assessment, Development and Evaluations. CONCLUSION The use of either non-perfusion or perfusion CT neuroimaging may have little to no effect on long-term clinical outcomes and sICH for late-presenting EVT patients. Perfusion CT neuroimaging may be associated with a reduced the risk of mortality. Evidence uncertainty warrants randomized trial data.
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Affiliation(s)
- Jose Danilo B. Diestro
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Abdelsimar T. Omar
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Yu-qing Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- CEBIM (Center for Evidence Based Integrative Medicine)-Clarity Collaboration, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Nottingham Ningbo GRADE Center, The University of Nottingham Ningbo, Ningbo, China
| | - Teruko Kishibe
- Health Sciences Library, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Melissa Mary Lannon
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Katrina Ignacio
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Anahita Malvea
- Division of Neurosurgery, Department of Surgery, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ange Diouf
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Vishnu Sharma
- Department of Neurology and Critical Care, McMaster University, Hamilton, ON, Canada
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The People’s Liberation Army, Xihu District, Hangzhou, China
| | - Mohammed A. Almekhlafi
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute and O’Brien Institute for Public Health, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | - Thanh N. Nguyen
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, United States of America
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Atif Zafar
- Department of Medicine, Division of Neurology, Unity Health- St. Michael’s Hospital, University of Toronto, Toronto, Ontario
| | - Vitor Mendes Pereira
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julian Spears
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas R. Marotta
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Dong Z, Deng S, Zhang J, Chen S, Ye Z, Zhang L, Hu R, Zhong C, Liu X, Qin C. Simplified stroke imaging selection modality for endovascular thrombectomy in the extended time window: systematic review and meta-analysis. J Neurointerv Surg 2023; 16:101-106. [PMID: 36597953 PMCID: PMC10803987 DOI: 10.1136/jnis-2022-019556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The impact of imaging selection modality on clinical outcomes of endovascular thrombectomy (EVT) in the 6-24-hour time window remains undetermined. We compared the clinical outcomes of a simplified stroke imaging selection modality using non-contrast computed tomography (NCCT)±CT angiography (CTA) with using advanced CT perfusion (CTP). METHODS PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception to 1 May 2022 to compare NCCT±CTA and CTP for patient selection for EVT in late-presenting stroke with large vessel occlusions (LVO). The primary outcome was the proportion of patients achieving functional independence (modified Rankin Scale score 0-2) within 180 days. The secondary outcomes included mortality within 90 days, successful recanalization, and any intracranial hemorrhage. RESULTS A total of 3419 patients in six articles were included in this meta-analysis. There was no significant difference between NCCT±CTA (no-CTP) and CTP in functional independence either in overall or subgroup analysis. However, the mortality in the no-CTP group was higher than in the CTP group. Furthermore, within the DAWN/DEFUSE 3-like subgroup, there were no significant differences in mortality, successful recanalization, and any intracranial hemorrhage between the two groups. CONCLUSION There was no significant difference between the simplified NCCT±CTA modality and the advanced CTP modality. The use of NCCT±CTA may represent a reasonable option for selecting patients for EVT in the extended time window, especially in the absence of CTP and acute phase MRI capabilities.
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Affiliation(s)
- Zimei Dong
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Neurology, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan, China
| | - Shan Deng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Shijian Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ziming Ye
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Limei Zhang
- Department of Cardiology, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan, China
| | - Ruiting Hu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Cai Zhong
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiuying Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chao Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Fainardi E, Busto G, Morotti A. Automated advanced imaging in acute ischemic stroke. Certainties and uncertainties. Eur J Radiol Open 2023; 11:100524. [PMID: 37771657 PMCID: PMC10523426 DOI: 10.1016/j.ejro.2023.100524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
The purpose of this is study was to review pearls and pitfalls of advanced imaging, such as computed tomography perfusion and diffusion-weighed imaging and perfusion-weighted imaging in the selection of acute ischemic stroke (AIS) patients suitable for endovascular treatment (EVT) in the late time window (6-24 h from symptom onset). Advanced imaging can quantify infarct core and ischemic penumbra using specific threshold values and provides optimal selection parameters, collectively called target mismatch. More precisely, target mismatch criteria consist of core volume and/or penumbra volume and mismatch ratio (the ratio between total hypoperfusion and core volumes) with precise cut-off values. The parameters of target mismatch are automatically calculated with dedicated software packages that allow a quick and standardized interpretation of advanced imaging. However, this approach has several limitations leading to a misclassification of core and penumbra volumes. In fact, automatic software platforms are affected by technical artifacts and are not interchangeable due to a remarkable vendor-dependent variability, resulting in different estimate of target mismatch parameters. In addition, advanced imaging is not completely accurate in detecting infarct core, that can be under- or overestimated. Finally, the selection of candidates for EVT remains currently suboptimal due to the high rates of futile reperfusion and overselection caused by the use of very stringent inclusion criteria. For these reasons, some investigators recently proposed to replace advanced with conventional imaging in the selection for EVT, after the demonstration that non-contrast CT ASPECTS and computed tomography angiography collateral evaluation are not inferior to advanced images in predicting outcome in AIS patients treated with EVT. However, other authors confirmed that CTP and PWI/DWI postprocessed images are superior to conventional imaging in establishing the eligibility of patients for EVT. Therefore, the routine application of automatic assessment of advanced imaging remains a matter of debate. Recent findings suggest that the combination of conventional and advanced imaging might improving our selection criteria.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Department of Neurological and Vision Sciences, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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Bai X, Zhang Y, Sui Y. Noncontrast versus perfusion CT to select endovascular therapy in an extended time window: Systematic review/meta-analysis. J Neuroimaging 2023; 33:889-897. [PMID: 37676117 DOI: 10.1111/jon.13152] [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: 04/24/2023] [Revised: 08/06/2023] [Accepted: 08/25/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND AND PURPOSE The effect of noncontrast CT (NCCT) on the eligibility for endovascular therapy (EVT) in an extended time window remains to be elucidated. We sought to assess the efficacy and safety of NCCT in comparison with CT perfusion (CTP) in selecting patients with acute ischemic stroke (AIS) for EVT 6-24 hours after onset. METHODS PubMed, Embase, and Cochrane libraries were searched from inception to August 31, 2022, to identify all studies reporting 90-day outcomes of EVT in patients with AIS in an extended time window. A meta-analysis was performed for the pooled risk ratio (RR) with 95% confidence interval (CI) using a random-effects model. The primary outcome used to assess efficacy was good functional independence, defined as a modified Rankin Scale score of 0-2 at 90 days. Secondary outcomes included successful reperfusion, symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. RESULTS We included four nonrandomized studies with a total of 2685 patients. The outcomes of good functional independence at 90 days (RR = 0.98; 95% CI: 0.88-1.07; I2 = 0%; p = .62), successful reperfusion (RR = 0.98; 95% CI: 0.93-1.03; I2 = 50.5%; p = .11), sICH (RR = 1.11; 95% CI: 0.55-2.21; I2 = 49.4%; p = .12), or mortality at 90 days (RR = 1.18; 95% CI: 0.99-1.40; I2 = 0%; p = .42) did not differ significantly between the two groups. CONCLUSIONS These findings suggest that NCCT is as effective as CTP in selecting patients for EVT in an extended time window.
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Affiliation(s)
- Xue Bai
- School of Public Health, China Medical University, Shenyang, China
| | - Yao Zhang
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang, China
| | - Yi Sui
- School of Public Health, China Medical University, Shenyang, China
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang, China
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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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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Kobeissi H, Ghozy S, Adusumilli G, Bilgin C, Tolba H, Amoukhteh M, Kadirvel R, Brinjikji W, Heit JJ, Rabinstein AA, Kallmes DF. CT Perfusion vs Noncontrast CT for Late Window Stroke Thrombectomy: A Systematic Review and Meta-analysis. Neurology 2023; 100:e2304-e2311. [PMID: 36990720 PMCID: PMC10259276 DOI: 10.1212/wnl.0000000000207262] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/21/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) in the late window (6-24 hours) can be evaluated with CT perfusion (CTP) or with noncontrast CT (NCCT) only. Whether outcomes differ depending on the type of imaging selection is unknown. We conducted a systematic review and meta-analysis comparing outcomes between CTP and NCCT for EVT selection in the late therapeutic window. METHODS This study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guidelines. A systematic literature review of the English language literature was conducted using Web of Science, Embase, Scopus, and PubMed databases. Studies focusing on late-window AIS undergoing EVT imaged through CTP and NCCT were included. Data were pooled using a random-effects model. The primary outcome of interest was rate of functional independence, defined as modified Rankin scale 0-2. The secondary outcomes of interest included rates of successful reperfusion, defined as thrombolysis in cerebral infarction 2b-3, mortality, and symptomatic intracranial hemorrhage (sICH). RESULTS Five studies with 3,384 patients were included in our analysis. There were comparable rates of functional independence (odds ratio [OR] 1.03, 95% CI 0.87-1.22; p = 0.71) and sICH (OR 1.09, 95% CI 0.58-2.04; p = 0.80) between the 2 groups. Patients imaged with CTP had higher rates of successful reperfusion (OR 1.31, 95% CI 1.05-1.64; p = 0.015) and lower rates of mortality (OR 0.79, 95% CI 0.65-0.96; p = 0.017). DISCUSSION Although recovery of functional independence after late-window EVT was not more common in patients selected by CTP when compared with patients selected by NCCT only, patients selected by CTP had lower mortality.
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Affiliation(s)
- Hassan Kobeissi
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN.
| | - Sherief Ghozy
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Gautam Adusumilli
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Cem Bilgin
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Hatem Tolba
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Melika Amoukhteh
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Ramanathan Kadirvel
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Waleed Brinjikji
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Jeremy J Heit
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - David F Kallmes
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
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7
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Dhillon PS, Butt W, Podlasek A, McConachie N, Lenthall R, Nair S, Malik L, Bhogal P, Makalanda HLD, Spooner O, Krishnan K, Sprigg N, Mortimer A, Booth TC, Lobotesis K, White P, James MA, Bath P, Dineen RA, England TJ. Association between time to treatment and clinical outcomes in endovascular thrombectomy beyond 6 hours without advanced imaging selection. J Neurointerv Surg 2023; 15:336-342. [PMID: 35296526 DOI: 10.1136/neurintsurg-2021-018564] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/24/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The effectiveness and safety of endovascular thrombectomy (EVT) in the late window (6-24 hours) for acute ischemic stroke (AIS) patients selected without advanced imaging is undetermined. We aimed to assess clinical outcomes and the relationship with time-to-EVT treatment beyond 6 hours of stroke onset without advanced neuroimaging. METHODS Patients who underwent EVT selected with non-contrast CT/CT angiography (without CT perfusion or MR imaging), between October 2015 and March 2020, were included from a national stroke registry. Functional and safety outcomes were assessed in both early (<6 hours) and late windows with time analyzed as a continuous variable. RESULTS Among 3278 patients, 2610 (79.6%) and 668 (20.4%) patients were included in the early and late windows, respectively. In the late window, for every hour delay, there was no significant association with shift towards poorer functional outcome (modified Rankin Scale (mRS)) at discharge (adjusted common OR 0.98, 95% CI 0.94 to 1.01, p=0.27) or change in predicted functional independence (mRS ≤2) (24.5% to 23.3% from 6 to 24 hours; aOR 0.99, 95% CI0.94 to 1.04, p=0.85). In contrast, predicted functional independence was time sensitive in the early window: 5.2% reduction per-hour delay (49.4% to 23.5% from 1 to 6 hours, p=0.0001). There were similar rates of symptomatic intracranial hemorrhage (sICH) (3.4% vs 4.6%, p=0.54) and in-hospital mortality (12.9% vs 14.6%, p=0.33) in the early and late windows, respectively, without a significant association with time. CONCLUSION In this real-world study, there was minimal change in functional disability, sICH and in-hospital mortality within and across the late window. While confirmatory randomized trials are needed, these findings suggest that EVT remains feasible and safe when performed in AIS patients selected without advanced neuroimaging between 6-24 hours from stroke onset.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK .,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, The Royal London Hospital Barts Health NHS Trust, London, UK
| | | | - Oliver Spooner
- Stroke Medicine, The Royal London Hospital Barts Health NHS Trust, London, UK
| | - Kailash Krishnan
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alex Mortimer
- Interventional Neuroradiology, Southmead Hospital North Bristol NHS Trust, Bristol, Bristol, UK
| | - Thomas Calvert Booth
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, London, UK
| | - Philip White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Martin A James
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Philip Bath
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Robert A Dineen
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Mental Health and Clinical Neuroscience, School of Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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8
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Ullberg T, von Euler M, Wester P, Arnberg F, Norrving B, Andersson T, Wassélius J. Endovascular thrombectomy for anterior circulation stroke beyond 6 hours of onset in Sweden 2015 to 2020: rates and outcomes in a nationwide register-based study. J Neurointerv Surg 2023; 15:330-335. [PMID: 35301261 PMCID: PMC10086473 DOI: 10.1136/neurintsurg-2022-018670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) for ischemic stroke (IS) beyond 6 hours has been proven effective in randomized controlled trials. We present data on implementation and outcomes for EVT beyond 6 hours in Sweden. METHODS We included all cases of anterior circulation IS caused by occlusion of the intracranial carotid artery, and the M1 or M2 segment of the middle cerebral artery, registered in two nationwide quality registers for stroke in 2015-2020. Three groups were defined from onset-to-groin-puncture (OTG) time: early window (<6 hours), late window (6-24 hours) known onset, late window last seen well (LSW). Favorable outcome (modified Rankin Scale (mRS) 0-2) and all-cause mortality at 90 days were the main outcomes, and symptomatic intracerebral hemorrhage (sICH) was the safety outcome. RESULTS Late window EVT increased from 0.3% of all IS in 2015 to 1.8% in 2020, and from 17.4% of all anterior circulation EVTs in 2015 to 32.9% in 2020. Of 2199 patients, 76.9% (n=1690) were early window EVTs and 23.1% late window EVTs (n=509; 141 known onset, 368 LSW). Median age was 73 years, and 46.2% were female, with no differences between groups. Favorable outcome did not differ between groups (early window 42.4%, late window known onset 38.9%, late window LSW 37.3% (p=0.737)) and remained similar when adjusted for baseline differences. sICH rates did not differ (early window 4.0%, late window known onset 2.1%, late window LSW 4.9% (p=0.413)). CONCLUSION Late window EVTs have increased substantially over time, and currently account for one third of anterior circulation treatments. Early and late window patients had similar outcomes.
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Affiliation(s)
- Teresa Ullberg
- Department of Diagnostic Radiology, Neuroradiology, Skåne University Hospital, Lund University, Lund, Sweden .,Department of Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Mia von Euler
- Department of Neurology, Örebro University Hospital, School of Medicine, Örebro University, Örebro, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden.,Departments of Neuroradiology Department of Clinical Science, Karolinska Institute, Danderyds Hospital, Stockholm, Sweden
| | - Fabian Arnberg
- Departments of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bo Norrving
- Department of Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Tommy Andersson
- Departments of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.,Departments of Radiology and Neurology, AZ Groeninge, Kortrijk, Belgium
| | - Johan Wassélius
- Department of Diagnostic Radiology, Neuroradiology, Skåne University Hospital, Lund University, Lund, Sweden
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9
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Cheng H, Yu Z, Ma G, Wang A, Jia B, Tong X, Ma N, Gao F, Mo D, Song L, Xuan S, Huo X, Zhang ZX, Ren Z, Miao Z. Does MRI add value in selecting patients for thrombectomy beyond the 6 h window? A matched-control analysis. Front Neurol 2023; 14:1135624. [PMID: 37139073 PMCID: PMC10149695 DOI: 10.3389/fneur.2023.1135624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/16/2023] [Indexed: 05/05/2023] Open
Abstract
Background Controversy exists regarding the need of advanced imaging for patient selection in the extended window. Aims To analyze the effect of initial imaging modalities on clinical outcomes of patients underwent MT in the extended window. Methods This was a retrospective analysis of a prospective registry, the Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke (ANGEL-ACT) registry which was conducted at 111 hospitals between November 2017 and March 2019 in China. Primary study cohort and Guideline like cohort were identified, in each cohort, two imaging modalities for patient selection in 6 to 24 h window were defined: (1) NCCT ± CTA, (2) MRI. Guideline-like cohort were further screened based on key features of the DAWN and DEFUSE 3 trials. The primary outcome was 90 day mRS. The safety outcomes were sICH, any ICH and 90-day mortality. Results After adjusting for covariates, there were no significant differences in 90 day mRS or any safety outcomes between two imaging modalities groups in both cohorts. All outcome measures of mixed-effects logistic regression model were consistent with propensity score matching model. Conclusion Our results indicate that patients presented with anterior large vessel occlusion in the extended time window can potentially benefit from MT even in the absence of MRI selection. This conclusion needs to be verified by the prospective randomized clinical trials.
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Affiliation(s)
- Huiran Cheng
- Department of Neurosurgery, The People's Hospital of Anyang City, Anyang, China
| | - Zequan Yu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sun Xuan
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zi-Xian Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zeguang Ren
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Zeguang Ren,
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Zhongrong Miao,
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10
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Lapa S, Neuhaus E, Harborth E, Neef V, Steinmetz H, Foerch C, Reitz SC. Dysphagia assessment in ischemic stroke after mechanical thrombectomy: When and how? Front Neurol 2022; 13:1024531. [PMID: 36504648 PMCID: PMC9726734 DOI: 10.3389/fneur.2022.1024531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/08/2022] [Indexed: 11/24/2022] Open
Abstract
Background Dysphagia is a frequent symptom in acute ischemic stroke (AIS). Endovascular treatment (EVT) has become the standard of care for acute stroke secondary to large vessel occlusion. Although standardized guidelines for poststroke dysphagia (PSD) management exist, they do not account for this setting in which patients receive EVT under general anesthesia. Therefore, the aim of this study was to evaluate PSD prevalence and severity, as well as an appropriate time point for the PSD evaluation, in patients undergoing EVT under general anesthesia (GA). Methods We prospectively included 54 AIS patients undergoing EVT under GA. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was performed within 24 h post-extubation in all patients. Patients presenting significant PSD received a second FEES-assessment to determine the course of dysphagia deficits over time. Dysphagia severity was rated according the Fiberoptic Dysphagia Severity Scale (FEDSS). Results At first FEES (FEES 1) assessment, performed in the median 13 h (IQR 5-17) post-extubation, 49/54 patients (90.7%) with dysphagia were observed with a median FEDSS of 4 (IQR 3-6). Severe dysphagia requiring tube feeding was identified in 28/54 (51.9%) subjects, whereas in 21 (38.9%) patients early oral diet with certain food restrictions could be initiated. In the follow up FEES examination conducted in the median 72 h (IQR 70-97 h) after initial FEES 34/49 (69.4%) patients still presented PSD. Age (p = 0.030) and ventilation time (p = 0.035) were significantly associated with the presence of PSD at the second FEES evaluation. Significant improvement of dysphagia frequency (p = 0.006) and dysphagia severity (p = 0.001) could be detected between the first and second dysphagia assessment. Conclusions PSD is a frequent finding both immediately within 24 h after extubation, as well as in the short-term course. In contrast to common clinical practice, to delay evaluation of swallowing for at least 24 h post-extubation, we recommend a timely assessment of swallowing function after extubation, as 50% of patients were safe to begin oral intake. Given the high amount of severe dysphagic symptoms, we strongly recommend application of instrumental swallowing diagnostics due to its higher sensitivity, when compared to clinical swallowing examination. Furthermore, advanced age, as well as prolonged intubation, were identified as significant predictors for delayed recovery of swallowing function.
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Affiliation(s)
- Sriramya Lapa
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany,*Correspondence: Sriramya Lapa
| | - Elisabeth Neuhaus
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Elena Harborth
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Vanessa Neef
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Helmuth Steinmetz
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Sarah Christina Reitz
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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11
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Yang Y, Cui T, Li Z, Li J, Duan T, Yuan Z, Wang C, Wan J, Li C, Zhang S, Li L, Hu F, Wu B. Benefits of Endovascular Treatment in Late Window for Acute Ischemic Stroke Selected without CT Perfusion: A Real-World Study. Clin Interv Aging 2022; 17:577-587. [PMID: 35497054 PMCID: PMC9041145 DOI: 10.2147/cia.s362119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/12/2022] [Indexed: 01/01/2023] Open
Abstract
Objective This study examined the functional outcomes and safety of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients owing to large vessel occlusion of the anterior circulation, presented during a late-time window (6–24 hours after last seen well (LSW)) in a real-world practice. Methods This was a retrospective analysis from a bi-center prospective cohort. According to the stroke treatment, patients with continuous Alberta Stroke Plan Early Aspect score (ASPECTS) ≥6 on non-contrast CT (NCCT) and moderate to good collateral state on CT angiography (CTA) were divided into EVT group and standard medical treatment (SMT) group. The primary outcome was the rate of functional independence (90-day mRS ≤2). Safety outcomes were the occurrence of symptomatic intracranial hemorrhage (sICH) and the 90-day mortality. Results Among the 288 enrolled patients (53.5% male, median age 64 years), there were 167 patients in the EVT group and 121 in the SMT group. After multivariable adjustments for potential confounders, EVT was associated with functional independence (adjusted OR: 3.052; 95% confidence interval (CI): 1.553–5.997; p = 0.001). In the PSM cohort, 44.2% (42/95) of patients in the EVT group versus 18.9% (18/95) in the SMT group achieved functional independence (OR: 3.39, 95% CI: 1.763–6.517), and there was a significant difference favoring EVT over the SMT in the overall distribution of mRS (OR: 2.170, 95% CI: 1.302–3.618) at 90 days. The rate of sICH did not differ between the EVT and SMT groups (10.5% vs 8.4%, p = 0.804) nor did 90-day mortality (18.9% vs 22.1%, p = 0.719). No interaction was found in p-values with statistical significance in subgroup analysis. Conclusion This real-world experience suggests that EVT for late-presenting stroke patients, based on small core on NCCT and moderate to good collaterals on CTA, is associated with better outcomes than SMT alone, with no increase in sICH and 90-day mortality rates.
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Affiliation(s)
- Yuan Yang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Ting Cui
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zuoxiao Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Jinglun Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Ting Duan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zhengzhou Yuan
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Changyi Wang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Jincheng Wan
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Cao Li
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Shujiang Zhang
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Ling Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Fayun Hu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Bo Wu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Correspondence: Bo Wu; Fayun Hu, Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China, Tel +86-18980602142; +86-15902861270, Email ;
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