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Lim J, Aguirre AO, Rattani A, Baig AA, Monteiro A, Kuo CC, Siddiqi M, Im J, Housley SB, McPheeters MJ, Ciecierska SSK, Jaikumar V, Vakharia K, Davies JM, Snyder KV, Levy EI, Siddiqui AH. Thrombectomy outcomes for acute ischemic stroke in lower-middle income countries: A systematic review and analysis. World Neurosurg X 2024; 23:100317. [PMID: 38511159 PMCID: PMC10950731 DOI: 10.1016/j.wnsx.2024.100317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Affiliation(s)
- Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Alexander O. Aguirre
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Abbas Rattani
- Department of Radiation Oncology, Tufts University Medical Center, Boston, MA, USA
| | - Ammad A. Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Cathleen C. Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Manhal Siddiqi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Justin Im
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Steven B. Housley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Matthew J. McPheeters
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | | | - Vinay Jaikumar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Kunal Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Jason M. Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Kenneth V. Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Elad I. Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Adnan H. Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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Kuram E, Karadeli HH. Fabrication of Shape Memory Polymer Endovascular Thrombectomy Device for Treating Ischemic Stroke. Macromol Rapid Commun 2024:e2400146. [PMID: 38704791 DOI: 10.1002/marc.202400146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/28/2024] [Indexed: 05/07/2024]
Abstract
Stroke is the second result for death and ischemic stroke constitutes most of all stroke cases. Ischemic stroke takes place when blood clot or embolus blocks cerebral vessel and interrupts blood flow, which often leads to brain damage, permanent disability, or death. There is a 4.5-h (golden hour) treatment window to restore blood flow prior to permanent neurological impairment results. Current stroke treatments consist mechanical system or thrombolytic drug therapy to disrupt or dissolve thrombus. Promising method for stroke treatment is mechanical retrieving of thrombi employing device deployed endovascularly. Advent of smart materials has led to research fabrication of several minimally invasive endovascular devices that take advantage of new materials capabilities. One of these capabilities is shape memory, is capability of material to store temporary form, then activate to primary shape as subjected to stimuli. Shape memory polymers (SMPs) are employed as good materials for thrombectomy device fabrication. Therefore, current review presents thrombectomy device development and fabrication with SMPs. Design, performance, limitations, and in vitro or in vivo clinical results of SMP-based thrombectomy devices are identified. Review also sheds light on SMP's future outlook and recommendations for thrombectomy device application, opening a new era for advanced materials in materials science.
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Affiliation(s)
- Emel Kuram
- Department of Mechanical Engineering, Gebze Technical University, Kocaeli, 41400, Turkey
| | - Hasan Hüseyin Karadeli
- Department of Neurology, Istanbul Medeniyet University Göztepe Prof. Dr. Süleyman Yalçın City Hospital, Istanbul, 34722, Turkey
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Bindal P, Kumar V, Kapil L, Singh C, Singh A. Therapeutic management of ischemic stroke. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2651-2679. [PMID: 37966570 DOI: 10.1007/s00210-023-02804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
Stroke is the third leading cause of years lost due to disability and the second-largest cause of mortality worldwide. Most occurrences of stroke are brought on by the sudden occlusion of an artery (ischemic stroke), but sometimes they are brought on by bleeding into brain tissue after a blood vessel has ruptured (hemorrhagic stroke). Alteplase is the only therapy the American Food and Drug Administration has approved for ischemic stroke under the thrombolysis category. Current views as well as relevant clinical research on the diagnosis, assessment, and management of stroke are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for the available therapeutic regimes in the past, present, and future. With the advent of endovascular therapy in 2015 and intravenous thrombolysis in 1995, the therapeutic options for ischemic stroke have expanded significantly. A novel approach such as vagus nerve stimulation could be life-changing for many stroke patients. Therapeutic hypothermia, the process of cooling the body or brain to preserve organ integrity, is one of the most potent neuroprotectants in both clinical and preclinical contexts. The rapid intervention has been linked to more favorable clinical results. This study focuses on the pathogenesis of stroke, as well as its recent advancements, future prospects, and potential therapeutic targets in stroke therapy.
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Affiliation(s)
- Priya Bindal
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Vishal Kumar
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Lakshay Kapil
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Charan Singh
- Department of Pharmaceutical Sciences, HNB Garhwal University (A Central University), Chauras Campus, Distt. Tehri Garhwal, Uttarakhand, 246174, India
| | - Arti Singh
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India.
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Yang Y, Gu B, Xu XY. In silico study of combination thrombolytic therapy with alteplase and mutant pro-urokinase for fibrinolysis in ischemic stroke. Comput Biol Med 2024; 171:108141. [PMID: 38367449 DOI: 10.1016/j.compbiomed.2024.108141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/03/2024] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
The synergistic advantage of combining tissue plasminogen activator (tPA) with pro-urokinase (proUK) for thrombolysis has been demonstrated in several in vitro experiments, and a single site proUK mutant (m-proUK) has been developed for better stability in plasma. Based on these studies, combination thrombolytic therapy with intravenous tPA and m-proUK has been suggested as a promising treatment for patients with ischemic stroke. This paper evaluates the efficacy and safety of the dual therapy by computational simulations of pharmacokinetics and pharmacodynamics coupled with a local fibrinolysis model. Seven dose regimens are simulated and compared with the standard intravenous tPA monotherapy. Our simulation results provide more insights into the complementary reaction mechanisms of tPA and m-proUK during clot lysis and demonstrate that the dual therapy can achieve a similar recanalization time (about 50 min) to tPA monotherapy, while keeping the circulating fibrinogen level within a normal range. Specifically, our results show that for all dual therapies with a 5 mg tPA bolus, the plasma concentration of fibrinogen remains stable at around 7.5 μM after a slow depletion over 50 min, whereas a rapid depletion of circulating fibrinogen (to 5 μM) is observed with the standard tPA therapy, indicating the potential advantage of dual therapy in reducing the risk of intracranial hemorrhage. Through simulations of varying dose combinations, it has been found that increasing tPA bolus can significantly affect fibrinogen level but only moderately improves recanalization time. Conversely, m-proUK doses and infusion duration exhibit a mild impact on fibrinogen level but significantly affect recanalization time. Therefore, future optimization of dose regimen should focus on limiting the tPA bolus while adjusting m-proUK dosage and infusion rate. Such adjustments could potentially maximize the therapeutic advantages of this combination therapy for ischemic stroke treatment.
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Affiliation(s)
- Yilin Yang
- Department of Chemical Engineering, Imperial College London, London, SW7 2AZ, United Kingdom.
| | - Boram Gu
- School of Chemical Engineering, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju, Republic of Korea.
| | - Xiao Yun Xu
- Department of Chemical Engineering, Imperial College London, London, SW7 2AZ, United Kingdom.
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Patel K, Hamedani AG, Taneja K, Koneru M, Wolfe J, Sprankle K, Patel P, Mullen MT, Siegler JE. Differential thrombectomy utilization across hospital classifications in the United States. J Stroke Cerebrovasc Dis 2023; 32:107401. [PMID: 37897885 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107401] [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: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/29/2023] [Indexed: 10/30/2023] Open
Abstract
OBJECTIVES To determine hospital-level factors associated with thrombectomy uptake. MATERIALS AND METHODS The Nationwide Emergency Department Sample was retrospectively queried to determine the total number of thrombectomies performed based on different hospital characteristics. Joint point analysis was used to determine which years were associated with significant increases in the number of high-volume thrombectomy centers (ostensibly defined as >50 thrombectomies/year), thrombectomy-capable centers (>15 thrombectomies/year), and total number of thrombectomies performed. Multivariable logistic regression was used to determine hospital factors associated with having an increased odds of performing thrombectomies, and of being classified as a high-volume thrombectomy or a thrombectomy-capable center. RESULTS Between 2007-2020 there was a stepwise increase in the number of thrombectomy-capable and high-volume thrombectomy centers in the United States. In 2020, there were a total of 15,705 thrombectomies performed, with 89 high-volume thrombectomy centers, and 359 thrombectomy-capable centers. The number of thrombectomy-capable centers significantly increased after 2011. After 2013 and 2016 there was a significant change in the growth rate of high-volume thrombectomy centers. There was also a significant increase in the total number of thrombectomies performed after 2016. Hospital characteristics that were associated with an increased likelihood of being classified as thrombectomy-capable or high-volume included trauma level 1 and 2 hospitals. CONCLUSIONS Between 2007 and 2020, there was a marked growth in thrombectomy utilization for acute ischemic stroke. This growth outpaced new diagnoses of ischemic stroke, and was driven largely by certain hospital types, with the greatest rises following seminal publications of positive randomized thrombectomy trials.
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Affiliation(s)
- Karan Patel
- Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Ali G Hamedani
- Departments of Neurology and Ophthalmology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jared Wolfe
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Pratit Patel
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Michael T Mullen
- Department of Neurology, Lewis Katz School of Medicine at Temple University, USA
| | - James E Siegler
- Cooper Medical School of Rowan University, Camden, NJ, USA; Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
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Li M, Lv Y, Wang M, Zhang Y, Pan Z, Luo Y, Zhang H, Wang J. Magnetic Resonance Perfusion-Weighted Imaging in Predicting Hemorrhagic Transformation of Acute Ischemic Stroke: A Retrospective Study. Diagnostics (Basel) 2023; 13:3404. [PMID: 37998540 PMCID: PMC10670343 DOI: 10.3390/diagnostics13223404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023] Open
Abstract
Hemorrhagic transformation (HT) is one of the common complications in patients with acute ischemic stroke (AIS). This study aims to investigate the value of different thresholds of Tmax generated from perfusion-weighted MR imaging (PWI) and the apparent diffusion coefficient (ADC) value in the prediction of HT in AIS. A total of 156 AIS patients were enrolled in this study, with 55 patients in the HT group and 101 patients in non-HT group. The clinical baseline data and multi-parametric MRI findings were compared between HT and non-HT groups to identify indicators related to HT. The optimal parameters for predicting HT and the corresponding cutoff values were obtained using the receiver operating characteristic curve analysis of the volumes of ADC < 620 × 10-6 mm2/s and Tmax > 6 s, 8 s, and 10 s. The results showed that the volumes of ADC < 620 × 10-6 mm2/s and Tmax > 6 s, 8 s, and 10 s in the HT group were all significantly larger than that in the non-HT group and were all independent risk factors for HT. Early measurement of the volume of Tmax > 10 s had the highest value, with a cutoff lesion volume of 10.5 mL.
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Affiliation(s)
- Ming Li
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (M.L.); (Z.P.)
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Yifan Lv
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Mingming Wang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Yaying Zhang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Zilai Pan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (M.L.); (Z.P.)
| | - Yu Luo
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Haili Zhang
- Southeast University Hospital, Southeast University, Nanjing 210096, China
| | - Jing Wang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
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Reyes-Esteves S, Kumar M, Kasner SE, Witsch J. Clinical Grading Scales and Neuroprognostication in Acute Brain Injury. Semin Neurol 2023; 43:664-674. [PMID: 37788680 DOI: 10.1055/s-0043-1775749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Prediction of neurological clinical outcome after acute brain injury is critical because it helps guide discussions with patients and families and informs treatment plans and allocation of resources. Numerous clinical grading scales have been published that aim to support prognostication after acute brain injury. However, the development and validation of clinical scales lack a standardized approach. This in turn makes it difficult for clinicians to rely on prognostic grading scales and to integrate them into clinical practice. In this review, we discuss quality measures of score development and validation and summarize available scales to prognosticate outcomes after acute brain injury. These include scales developed for patients with coma, cardiac arrest, ischemic stroke, nontraumatic intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury; for each scale, we discuss available validation studies.
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Affiliation(s)
- Sahily Reyes-Esteves
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monisha Kumar
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott E Kasner
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jens Witsch
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Abel F, Schubert T, Winklhofer S. Advanced Neuroimaging With Photon-Counting Detector CT. Invest Radiol 2023; 58:472-481. [PMID: 37158466 DOI: 10.1097/rli.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
ABSTRACT Photon-counting detector computed tomography (PCD-CT) is an emerging technology and promises the next step in CT evolution. Photon-counting detectors count the number of individual incoming photons and assess the energy level of each of them. These mechanisms differ substantially from conventional energy-integrating detectors. The new technique has several advantages, including lower radiation exposure, higher spatial resolution, reconstruction of images with less beam-hardening artifacts, and advanced opportunities for spectral imaging. Research PCD-CT systems have already demonstrated promising results, and recently, the first whole-body full field-of-view PCD-CT scanners became clinically available. Based on published studies of preclinical systems and the first experience with clinically approved scanners, the performance can be translated to valuable neuroimaging applications, including brain imaging, intracranial and extracranial CT angiographies, or head and neck imaging with detailed assessment of the temporal bone. In this review, we will provide an overview of the current status in neuroimaging with upcoming and potential clinical applications.
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Affiliation(s)
- Frederik Abel
- From the Department of Diagnostic and Interventional Radiology
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sebastian Winklhofer
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Ag Lamat MSN, Abd Rahman MSH, Wan Zaidi WA, Yahya WNNW, Khoo CS, Hod R, Tan HJ. Qualitative electroencephalogram and its predictors in the diagnosis of stroke. Front Neurol 2023; 14:1118903. [PMID: 37377856 PMCID: PMC10291181 DOI: 10.3389/fneur.2023.1118903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/16/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Stroke is a typical medical emergency that carries significant disability and morbidity. The diagnosis of stroke relies predominantly on the use of neuroimaging. Accurate diagnosis is pertinent for management decisions of thrombolysis and/or thrombectomy. Early identification of stroke using electroencephalogram (EEG) in the clinical assessment of stroke has been underutilized. This study was conducted to determine the relevance of EEG and its predictors with the clinical and stroke features. Methods A cross-sectional study was carried out where routine EEG assessment was performed in 206 consecutive acute stroke patients without seizures. The demographic data and clinical stroke assessment were collated using the National Institutes of Health Stroke Scale (NIHSS) score with neuroimaging. Associations between EEG abnormalities and clinical features, stroke characteristics, and NIHSS scores were evaluated. Results The mean age of the study population was 64.32 ± 12 years old, with 57.28% consisting of men. The median NIHSS score on admission was 6 (IQR 3-13). EEG was abnormal in more than half of the patients (106, 51.5%), which consisted of focal slowing (58, 28.2%) followed by generalized slowing (39, 18.9%) and epileptiform changes (9, 4.4%). NIHSS score was significantly associated with focal slowing (13 vs. 5, p < 0.05). Type of stroke and imaging characteristics were significantly associated with EEG abnormalities (p < 0.05). For every increment in NIHSS score, there are 1.08 times likely for focal slowing (OR 1.089; 95% CI 1.033, 1.147, p = 0.002). Anterior circulation stroke has 3.6 times more likely to have abnormal EEG (OR 3.628; 95% CI 1.615, 8.150, p = 0.002) and 4.55 times higher to exhibit focal slowing (OR 4.554; 95% CI 1.922, 10.789, p = 0.01). Conclusion The type of stroke and imaging characteristics are associated with EEG abnormalities. Predictors of focal EEG slowing are NIHSS score and anterior circulation stroke. The study emphasized that EEG is a simple yet feasible investigational tool, and further plans for advancing stroke evaluation should consider the inclusion of this functional modality.
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Affiliation(s)
- Mohd Syahrul Nizam Ag Lamat
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Muhammad Samir Haziq Abd Rahman
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Wan Asyraf Wan Zaidi
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Wan Nur Nafisah Wan Yahya
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Ching Soong Khoo
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Rozita Hod
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
- Department of Community Health, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Hui Jan Tan
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
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10
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Zhang B, Jiang X. Magnetic Nanoparticles Mediated Thrombolysis-A Review. IEEE OPEN JOURNAL OF NANOTECHNOLOGY 2023; 4:109-132. [PMID: 38111792 PMCID: PMC10727495 DOI: 10.1109/ojnano.2023.3273921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Nanoparticles containing thrombolytic medicines have been developed for thrombolysis applications in response to the increasing demand for effective, targeted treatment of thrombosis disease. In recent years, there has been a great deal of interest in nanoparticles that can be navigated and driven by a magnetic field. However, there are few review publications concerning the application of magnetic nanoparticles in thrombolysis. In this study, we examine the current state of magnetic nanoparticles in the application of in vitro and in vivo thrombolysis under a static or dynamic magnetic field, as well as the combination of magnetic nanoparticles with an acoustic field for dual-mode thrombolysis. We also discuss four primary processes of magnetic nanoparticles mediated thrombolysis, including magnetic nanoparticle targeting, magnetic nanoparticle trapping, magnetic drug release, and magnetic rupture of blood clot fibrin networks. This review will offer unique insights for the future study and clinical development of magnetic nanoparticles mediated thrombolysis approaches.
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Affiliation(s)
- Bohua Zhang
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695 USA
| | - Xiaoning Jiang
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 27695 USA
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11
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Routledge H, Curzen N. Percutaneous management of acute ischaemic stroke. Heart 2023; 109:794-800. [PMID: 36737223 DOI: 10.1136/heartjnl-2022-321604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
| | - Nick Curzen
- Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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12
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Younger DS. Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:305-346. [PMID: 37620077 DOI: 10.1016/b978-0-323-98817-9.00025-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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13
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Pierre K, Perez-Vega C, Fusco A, Olowofela B, Hatem R, Elyazeed M, Azab M, Lucke-Wold B. Updates in mechanical thrombectomy. EXPLORATION OF NEUROSCIENCE 2022; 1:83-99. [PMID: 36655054 PMCID: PMC9845048 DOI: 10.37349/en.2022.00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 01/01/2023]
Abstract
Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.
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Affiliation(s)
- Kevin Pierre
- Department of Radiology, University of Florida, Gainesville, FL 32608, USA
| | - Carlos Perez-Vega
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Anna Fusco
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Bankole Olowofela
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Rami Hatem
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mohammed Elyazeed
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Mohammed Azab
- Biomolecular Sciences Graduate Program, Boise State University, Boise, ID 83725, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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14
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Lithium Biological Action Mechanisms after Ischemic Stroke. Life (Basel) 2022; 12:life12111680. [DOI: 10.3390/life12111680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Lithium is a source of great scientific interest because although it has such a simple structure, relatively easy-to-analyze chemistry, and well-established physical properties, the plethora of effects on biological systems—which influence numerous cellular and molecular processes through not entirely explained mechanisms of action—generate a mystery that modern science is still trying to decipher. Lithium has multiple effects on neurotransmitter-mediated receptor signaling, ion transport, signaling cascades, hormonal regulation, circadian rhythm, and gene expression. The biochemical mechanisms of lithium action appear to be multifactorial and interrelated with the functioning of several enzymes, hormones, vitamins, and growth and transformation factors. The widespread and chaotic marketing of lithium salts in potions and mineral waters, always at inadequate concentrations for various diseases, has contributed to the general disillusionment with empirical medical hypotheses about the therapeutic role of lithium. Lithium salts were first used therapeutically in 1850 to relieve the symptoms of gout, rheumatism, and kidney stones. In 1949, Cade was credited with discovering the sedative effect of lithium salts in the state of manic agitation, but frequent cases of intoxication accompanied the therapy. In the 1960s, lithium was shown to prevent manic and also depressive recurrences. This prophylactic effect was first demonstrated in an open-label study using the “mirror” method and was later (after 1970) confirmed by several placebo-controlled double-blind studies. Lithium prophylaxis was similarly effective in bipolar and also unipolar patients. In 1967, the therapeutic value of lithemia was determined, included in the range of 0.5–1.5 mEq/L. Recently, new therapeutic perspectives on lithium are connected with improved neurological outcomes after ischemic stroke. The effects of lithium on the development and maintenance of neuroprotection can be divided into two categories: short-term effects and long-term effects. Unfortunately, the existing studies do not fully explain the lithium biological action mechanisms after ischemic stroke.
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15
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You JS, Kim JY, Yenari MA. Therapeutic hypothermia for stroke: Unique challenges at the bedside. Front Neurol 2022; 13:951586. [PMID: 36262833 PMCID: PMC9575992 DOI: 10.3389/fneur.2022.951586] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/08/2022] [Indexed: 12/24/2022] Open
Abstract
Therapeutic hypothermia has shown promise as a means to improving neurological outcomes at several neurological conditions. At the clinical level, it has been shown to improve outcomes in comatose survivors of cardiac arrest and in neonatal hypoxic ischemic encephalopathy, but has yet to be convincingly demonstrated in stroke. While numerous preclinical studies have shown benefit in stroke models, translating this to the clinical level has proven challenging. Major obstacles include cooling patients with typical stroke who are awake and breathing spontaneously but often have significant comorbidities. Solutions around these problems include selective brain cooling and cooling to lesser depths or avoiding hyperthermia. This review will cover the mechanisms of protection by therapeutic hypothermia, as well as recent progress made in selective brain cooling and the neuroprotective effects of only slightly lowering brain temperature. Therapeutic hypothermia for stroke has been shown to be feasible, but has yet to be definitively proven effective. There is clearly much work to be undertaken in this area.
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Affiliation(s)
- Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong Youl Kim
- Department of Anatomy, Yonsei University College of Medicine, Seoul, South Korea
| | - Midori A. Yenari
- Department of Neurology, The San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Midori A. Yenari
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16
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The impacts of anesthetic regimens on the middle cerebral artery occlusion outcomes in male rats. Neuroreport 2022; 33:561-568. [DOI: 10.1097/wnr.0000000000001816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere 2022; 6:e750. [PMID: 35924068 PMCID: PMC9281983 DOI: 10.1097/hs9.0000000000000750] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/01/2022] [Indexed: 01/19/2023] Open
Abstract
In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.
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18
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Bertog SC, Sievert K, Grunwald IQ, Sharma A, Hornung M, Kühn AL, Vaskelyte L, Hofmann I, Gafoor S, Reinartz M, Matic P, Sievert H. Acute Stroke Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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19
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Kaplan-Arabaci O, Acari A, Ciftci P, Gozuacik D. Glutamate Scavenging as a Neuroreparative Strategy in Ischemic Stroke. Front Pharmacol 2022; 13:866738. [PMID: 35401202 PMCID: PMC8984161 DOI: 10.3389/fphar.2022.866738] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/08/2022] [Indexed: 12/17/2022] Open
Abstract
Stroke is the second highest reason of death in the world and the leading cause of disability. The ischemic stroke makes up the majority of stroke cases that occur due to the blockage of blood vessels. Therapeutic applications for ischemic stroke include thrombolytic treatments that are in limited usage and only applicable to less than 10% of the total stroke patients, but there are promising new approaches. The main cause of ischemic neuronal death is glutamate excitotoxicity. There have been multiple studies focusing on neuroprotection via reduction of glutamate both in ischemic stroke and other neurodegenerative diseases that ultimately failed due to the obstacles in delivery. At that point, systemic glutamate grabbing, or scavenging is an ingenious way of decreasing glutamate levels upon ischemic stroke. The main advantage of this new therapeutic method is the scavengers working in the circulating blood so that there is no interference with the natural brain neurophysiology. In this review, we explain the molecular mechanisms of ischemic stroke, provide brief information about existing drugs and approaches, and present novel systemic glutamate scavenging methods. This review hopefully will elucidate the potential usage of the introduced therapeutic approaches in stroke patients.
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Affiliation(s)
- Oykum Kaplan-Arabaci
- Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey.,Sabancı University Nanotechnology Research and Application Center (SUNUM), Istanbul, Turkey
| | - Alperen Acari
- Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Pinar Ciftci
- Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Devrim Gozuacik
- Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey.,Sabancı University Nanotechnology Research and Application Center (SUNUM), Istanbul, Turkey.,School of Medicine, Koç University, Istanbul, Turkey
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20
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Nito C, Suda S, Nitahara-Kasahara Y, Okada T, Kimura K. Dental-Pulp Stem Cells as a Therapeutic Strategy for Ischemic Stroke. Biomedicines 2022; 10:biomedicines10040737. [PMID: 35453487 PMCID: PMC9032844 DOI: 10.3390/biomedicines10040737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/03/2022] [Accepted: 03/16/2022] [Indexed: 02/01/2023] Open
Abstract
Regenerative medicine aims to restore human functions by regenerating organs and tissues using stem cells or living tissues for the treatment of organ and tissue defects or dysfunction. Clinical trials investigating the treatment of cerebral infarction using mesenchymal stem cells, a type of somatic stem cell therapy, are underway. The development and production of regenerative medicines using somatic stem cells is expected to contribute to the treatment of cerebral infarction, a central nervous system disease for which there is no effective treatment. Numerous experimental studies have shown that cellular therapy, including the use of human dental pulp stem cells, is an attractive strategy for patients with ischemic brain injury. This review describes the basic research, therapeutic mechanism, clinical trials, and future prospects for dental pulp stem cell therapy, which is being investigated in Japan in first-in-human clinical trials for the treatment of patients with acute cerebral ischemia.
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Affiliation(s)
- Chikako Nito
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (S.S.); (K.K.)
- Collaborative Research Center, Laboratory for Clinical Research, Nippon Medical School, Tokyo 113-8603, Japan
- Correspondence: ; Tel.: +81-3-3822-2131; Fax: +81-3-5814-6176
| | - Satoshi Suda
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (S.S.); (K.K.)
| | - Yuko Nitahara-Kasahara
- Division of Molecular and Medical Genetics, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan; (Y.N.-K.); (T.O.)
| | - Takashi Okada
- Division of Molecular and Medical Genetics, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan; (Y.N.-K.); (T.O.)
| | - Kazumi Kimura
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (S.S.); (K.K.)
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21
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Chalet L, Boutelier T, Christen T, Raguenes D, Debatisse J, Eker OF, Becker G, Nighoghossian N, Cho TH, Canet-Soulas E, Mechtouff L. Clinical Imaging of the Penumbra in Ischemic Stroke: From the Concept to the Era of Mechanical Thrombectomy. Front Cardiovasc Med 2022; 9:861913. [PMID: 35355966 PMCID: PMC8959629 DOI: 10.3389/fcvm.2022.861913] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/11/2022] [Indexed: 01/01/2023] Open
Abstract
The ischemic penumbra is defined as the severely hypoperfused, functionally impaired, at-risk but not yet infarcted tissue that will be progressively recruited into the infarct core. Early reperfusion aims to save the ischemic penumbra by preventing infarct core expansion and is the mainstay of acute ischemic stroke therapy. Intravenous thrombolysis and mechanical thrombectomy for selected patients with large vessel occlusion has been shown to improve functional outcome. Given the varying speed of infarct core progression among individuals, a therapeutic window tailored to each patient has recently been proposed. Recent studies have demonstrated that reperfusion therapies are beneficial in patients with a persistent ischemic penumbra, beyond conventional time windows. As a result, mapping the penumbra has become crucial in emergency settings for guiding personalized therapy. The penumbra was first characterized as an area with a reduced cerebral blood flow, increased oxygen extraction fraction and preserved cerebral metabolic rate of oxygen using positron emission tomography (PET) with radiolabeled O2. Because this imaging method is not feasible in an acute clinical setting, the magnetic resonance imaging (MRI) mismatch between perfusion-weighted imaging and diffusion-weighted imaging, as well as computed tomography perfusion have been proposed as surrogate markers to identify the penumbra in acute ischemic stroke patients. Transversal studies comparing PET and MRI or using longitudinal assessment of a limited sample of patients have been used to define perfusion thresholds. However, in the era of mechanical thrombectomy, these thresholds are debatable. Using various MRI methods, the original penumbra definition has recently gained a significant interest. The aim of this review is to provide an overview of the evolution of the ischemic penumbra imaging methods, including their respective strengths and limitations, as well as to map the current intellectual structure of the field using bibliometric analysis and explore future directions.
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Affiliation(s)
- Lucie Chalet
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Olea Medical, La Ciotat, France
| | | | - Thomas Christen
- Grenoble Institut Neurosciences, INSERM, U1216, Univ. Grenoble Alpes, Grenoble, France
| | | | - Justine Debatisse
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Omer Faruk Eker
- CREATIS, CNRS UMR-5220, INSERM U1206, Université Lyon 1, Villeurbanne, France
- Neuroradiology Department, Hospices Civils of Lyon, Lyon, France
| | - Guillaume Becker
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Norbert Nighoghossian
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
| | - Tae-Hee Cho
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
| | - Emmanuelle Canet-Soulas
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Laura Mechtouff
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
- *Correspondence: Laura Mechtouff
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22
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Wassélius J, Arnberg F, von Euler M, Wester P, Ullberg T. Endovascular thrombectomy for acute ischemic stroke. J Intern Med 2022; 291:303-316. [PMID: 35172028 DOI: 10.1111/joim.13425] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This review describes the evolution of endovascular treatment for acute ischemic stroke, current state of the art, and the challenges for the next decade. The rapid development of endovascular thrombectomy (EVT), from the first attempts into standard of care on a global scale, is one of the major achievements in modern medicine. It was possible thanks to the establishment of a scientific framework for patient selection, assessment of stroke severity and outcome, technical development by dedicated physicians and the MedTech industry, including noninvasive imaging for patient selection, and radiological outcome evaluation. A series of randomized controlled trials on EVT in addition to intravenous thrombolytics, with overwhelmingly positive results for anterior circulation stroke within 6 h of onset regardless of patient characteristics with a number needed to treat of less than 3 for any positive shift in outcome, paved the way for a rapid introduction of EVT into clinical practice. Within the "extended" time window of 6-24 h, the effect has been even greater for patients with salvageable brain tissue according to perfusion imaging with a number needed to treat below 2. Even so, EVT is only available for a small portion of stroke patients, and successfully recanalized EVT patients do not always achieve excellent functional outcome. The major challenges in the years to come include rapid prehospital detection of stroke symptoms, adequate clinical and radiological diagnosis of severe ischemic stroke cases, enabling effective recanalization by EVT in dedicated angiosuites, followed by personalized post-EVT stroke care.
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Affiliation(s)
- Johan Wassélius
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Fabian Arnberg
- Department of Neuroradiology, Karolinska University Hospital, Solna, Sweden
| | - Mia von Euler
- School of Medicine, Örebro University, Örebro, SE-70182, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Teresa Ullberg
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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23
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Efficacy and safety of tirofiban injection with intracranial stenting in early reocclusion due to intracranial atherosclerosis. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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24
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Sadeh M, Patel S, Souter J, Chiu R, Ansari D, Atwal GS. Clinical and radiographic risk indicators for decompressive hemicraniectomy in patients with ischemic stroke: an institutional and national analysis. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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25
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Endovascular Intervention in Acute Ischemic Stroke: History and Evolution. Biomedicines 2022; 10:biomedicines10020418. [PMID: 35203626 PMCID: PMC8962313 DOI: 10.3390/biomedicines10020418] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 12/26/2022] Open
Abstract
Stroke is a leading cause of serious long-term disability in the US. Endovascular therapy (EVT), in the form of mechanical thrombectomy, is now a standard of care for patients with acute ischemic stroke with a large vessel occlusion. This article reviews the evolution of EVT in the management of acute ischemic stroke and how it has led to the concept of tissue window over the widely publicized time window.
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26
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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27
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Romano DG, Frauenfelder G, Diana F, Saponiero R. JET 7 catheter for direct aspiration in carotid T occlusions: preliminary experience and literature review. Radiol Med 2022; 127:330-340. [PMID: 35034326 DOI: 10.1007/s11547-022-01451-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 01/03/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We report our preliminary experience with the Penumbra JET 7 reperfusion catheter (JET 7), a new large-bore (0.072″) aspiration catheter, in patients with acute ischemic stroke (AIS) due to carotid T occlusion. METHODS Data of all eligible patients who received A Direct Aspiration First Pass Technique (ADAPT) for AIS due to carotid T occlusion at our center from March 2018 through June 2020 were retrospectively reviewed. The safety and performance of JET 7 cases and smaller large-bore catheters (LBCs) were compared. RESULTS JET 7 was used in 19 patients, and smaller LBCs were used in 41 patients. Median puncture to revascularization time was significantly different between the JET 7 and the smaller LBCs (16 vs. 27 min; P = 0.011). The rate of patients who received rescue therapy with a stent retriever was also significantly different between the JET 7 cases and the smaller LBCs cases (5.3% vs. 22.0%; P = 0.046). Successful revascularization (TICI ≥ 2b) was achieved in 94.7% of JET 7 cases and 75.6% of smaller LBCs cases (P = 0.148). Good functional outcome (mRS 0-2) at 90 days occurred in 63.2% of JET 7 cases and 46.3% of smaller LBCs cases (P = 0.274). CONCLUSIONS In this early experience, ADAPT with JET 7 could be considered as one of the possible first-line therapies in carotid T occlusion, showing good rate of vascularization and lower rate of rescue therapy in comparison with smaller LBCs.
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Affiliation(s)
- Daniele Giuseppe Romano
- Department of Neuroradiology, A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Via San Leonardo 1, 84100, Salerno, Italy
| | - Giulia Frauenfelder
- Department of Neuroradiology, A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Via San Leonardo 1, 84100, Salerno, Italy.
| | - Francesco Diana
- Department of Neuroradiology, A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Via San Leonardo 1, 84100, Salerno, Italy
| | - Renato Saponiero
- Department of Neuroradiology, A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Via San Leonardo 1, 84100, Salerno, Italy
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28
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Sattenberg RJ, Atchaneeyasakul K, Meckler J, Saver JL, Gobin YP, Liebeskind DS. Cerebral Angiography. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00049-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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29
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Kadakia KT, Beckman AL, Ross JS, Krumholz HM. Renewing the Call for Reforms to Medical Device Safety-The Case of Penumbra. JAMA Intern Med 2022; 182:59-65. [PMID: 34842892 DOI: 10.1001/jamainternmed.2021.6626] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Strengthening premarket and postmarket surveillance of medical devices has long been an area of focus for health policy makers. The recent class I recall (the most serious of the US Food and Drug Administration [FDA] recalls) of reperfusion catheters manufactured by Penumbra, a US-based medical device company, illustrates issues of device safety and oversight that mandate attention. OBJECTIVES To review the regulatory history and clinical evidence of the Penumbra JET 7 Reperfusion Catheter with Xtra Flex Technology (JET 7) and use the device recall as a case study of the challenges associated with clinical evaluation, transparency, and oversight of medical devices in the US. EVIDENCE Regulatory history and clinical evidence for the Penumbra medical devices were analyzed through a qualitative review of decision letters in the Access FDA database for medical devices and medical device reports in the Manufacturer and User Facility Device Experience database and a review of market data (eg, earnings calls, company communications) and clinical literature. FINDINGS The JET 7 device was subjected to a class I recall following more than 200 adverse event reports, 14 of which involved patient deaths. Regulatory analysis indicated that each of the Penumbra reperfusion catheters was cleared under the 510(k) pathway (which allows devices to be authorized with limited to no clinical evidence), with limited submission of either new clinical or animal data. Clinical evidence for Penumbra devices was generated from nonrandomized, single-arm trials with small sample sizes. The regulatory issues raised by JET 7 are reflective of broader challenges for medical device regulation. Opportunities for reform include strengthening premarket evidence requirements, requiring safety reporting with unique device identifiers, and mandating active methods of postmarket surveillance. CONCLUSIONS AND RELEVANCE The case study of JET 7 highlights the long-standing gaps in medical device oversight and renews the impetus to build on the Institute of Medicine recommendations and reform FDA medical device regulation to protect public health.
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Affiliation(s)
| | - Adam L Beckman
- Harvard Medical School, Boston, Massachusetts.,Harvard Business School, Boston, Massachusetts
| | - Joseph S Ross
- Section of General Internal Medicine and the National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Harlan M Krumholz
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Chen LL, Yan SM, Wang WT, Zhang S, Liu HM, Yuan XY, Yang X, Gu P. Cohort study of THRIVE predicting adverse outcomes in acute ischemic stroke of the anterior circulation and posterior circulation after 3 months and 1 year of follow-up. J Clin Neurosci 2021; 96:33-37. [PMID: 34971994 DOI: 10.1016/j.jocn.2021.12.004] [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: 05/05/2021] [Revised: 11/16/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the difference of Totaled Health Risks In Vascular Events (THRIVE) in predicting adverse outcomes in acute ischemic stroke (AIS) of the anterior circulation and posterior circulation at 3-month and 1-year follow-up. METHODS A total of 858 patients with AIS were followed up for 3 months and 1 year, and their data prospectively collected. The occurrence of death or moderate to severe disability (modified Rankin Scale ≥ 3 points) was regarded as the endpoint. MedCalc software was used to create the THRIVE receiver operating characteristic curve. The area under the curve (AUC) was calculated to compare the THRIVE scale in predicting adverse outcomes in AIS of the anterior and posterior circulation and compare the differences. RESULTS At 3-month follow-up, the AUC of THRIVE was 0.685 (95% CI 0.644-0.724) for AIS of the anterior circulation and 0.709 (95% CI 0.647-0.765) for AIS of the posterior circulation. The area difference between them was 0.0235 (95% CI -0.0728-0.120, P = 0.6330[>0.05]). The AUC of THRIVE for AIS in the anterior circulation at 1 year was 0.701 (95% CI 0.660-0.740), and that for AIS in the posterior circulation at 1 year was 0.747 (95% CI 0.687-0.800). The area difference between them was 0.0458 (95% CI -0.0489-0.140, P = 0.3436 [>0.05]). The difference was not statistically significant. CONCLUSION THRIVE can well predict the short-term and long-term adverse prognosis of AIS in the anterior and posterior circulation and has the same predictive effect.
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Affiliation(s)
- Li-Li Chen
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, China
| | - Shuang-Mei Yan
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, China
| | - Wen-Ting Wang
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, China
| | - Sai Zhang
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, China
| | - Hui-Miao Liu
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, China
| | - Xiao-Yang Yuan
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, China
| | - Xu Yang
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing 100049, China.
| | - Ping Gu
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, China.
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Mastrorilli D, Mezzetto L, D'Oria M, Fiorini R, Lepidi S, Scorsone L, Veraldi E, Veraldi GF. NIHSS score at admission can predict functional outcomes in patients with ischemic stroke undergoing carotid endarterectomy. J Vasc Surg 2021; 75:1661-1669.e2. [PMID: 34954269 DOI: 10.1016/j.jvs.2021.11.079] [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: 09/17/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of present study was to evaluate the prognostic impact of National Institutes of Health Stroke Scale (NIHSS) score in patients undergoing acute CEA, and to assess clinical and morphological factors that could predict worse outcomes. METHODS The data of 183 consecutive patients who have undergone CEA after ischemic stroke was analyzed from January 2015 to January 2021. Patients were divided into two groups using the NIHSS cut off point of 4. Functional dependence was assessed on hospital discharge and 90 days after. RESULTS In total, 102 patients (55.7%) had a minor stroke (Group A: NIHSS ≤ 4), whereas 81 patients (44.3%) had a moderate-major stroke (Group B: NIHSS > 4). Group A and group B showed significant differences in their intracranial anatomic features: presence of incomplete Circle of Willis (7.8% vs 17.3%; p=.05), volume of Cerebral ischemic lesion volume ≥4000 mm3 (5.9 % vs 24.7%; p=<.001), and high ASPECTS of 8 to 10 (75.5% vs 44.4%; p=<.001). The overall rate of combined perioperative stroke/myocardial infarction/death was 1.1%, with no strokes recorded during the waiting time to carotid endarterectomy (CEA). Patients in group A had a lower rate of functional dependence at discharge (4.9% vs. 35.8%; p = <.001) and at 90 days after index stroke event (2.5% vs. 19.6%; p = <.001) versus those in group B. Using multivariate binary logistic regression, admission NIHSS>4 was significantly associated with higher odds of functional dependence at discharge (OR= 7.9, 95%CI= 2.7-18.5, p = <.001) and at 90 days (OR= 10.4, 95%CI= 2.7-19.3, p = .002). CONCLUSIONS NIHSS>4 at admission will increase the risk of having higher mRS scores both at hospital discharge and at 90 days after index stroke event. acute CEA was safe and feasible in patients with ischemic stroke, even if they had previously undergone intravenous thrombolysis.
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Affiliation(s)
- Davide Mastrorilli
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy.
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Roberta Fiorini
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Lorenzo Scorsone
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
| | - Edoardo Veraldi
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
| | - Gian Franco Veraldi
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
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Preclinical modeling of mechanical thrombectomy. J Biomech 2021; 130:110894. [PMID: 34915309 DOI: 10.1016/j.jbiomech.2021.110894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/21/2022]
Abstract
Mechanical thrombectomy to treat large vessel occlusions (LVO) causing a stroke is one of the most effective treatments in medicine, with a number needed to treat to improve clinical outcomes as low as 2.6. As the name implies, it is a mechanical solution to a blocked artery and modeling these mechanics preclinically for device design, regulatory clearance and high-fidelity physician training made clinical applications possible. In vitro simulation of LVO is extensively used to characterize device performance in representative vascular anatomies with physiologically accurate hemodynamics. Embolus analogues, validated against clots extracted from patients, provide a realistic simulated use experience. In vitro experimentation produces quantitative results such as particle analysis of distal emboli generated during the procedure, as well as pressure and flow throughout the experiment. Animal modeling, used mostly for regulatory review, allows estimation of device safety. Other than one recent development, nearly all animal modeling does not incorporate the desired target organ, the brain, but rather is performed in the extracranial circulation. Computational modeling of the procedure remains at the earliest stages but represents an enormous opportunity to rapidly characterize and iterate new thrombectomy concepts as well as optimize procedure workflow. No preclinical model is a perfect surrogate; however, models available can answer important questions during device development and have to date been successful in delivering efficacious and safe devices producing excellent clinical outcomes. This review reflects on the developments of preclinical modeling of mechanical thrombectomy with particular focus on clinical translation, as well as articulate existing gaps requiring additional research.
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Hurd MD, Goel I, Sakai Y, Teramura Y. Current status of ischemic stroke treatment: From thrombolysis to potential regenerative medicine. Regen Ther 2021; 18:408-417. [PMID: 34722837 PMCID: PMC8517544 DOI: 10.1016/j.reth.2021.09.009] [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: 07/20/2021] [Revised: 09/16/2021] [Accepted: 09/29/2021] [Indexed: 12/22/2022] Open
Abstract
Ischemic stroke is a major cause of death and disability worldwide and is expected to increase in the future with the aging population. Currently, there are no clinically available treatments for damage sustained during an ischemic stroke, but much research is being conducted in this area. In this review, we will introduce current ischemic stroke treatments along with their limitations, as well as research on potential short and long-term future treatments. There are advantages and disadvantages in these potential treatments, but our understanding of these methods and their effectiveness in clinical trials are improving. We are confident that some future treatments introduced in this review will become commonly used in clinical settings in the future.
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Affiliation(s)
- Mason Daniel Hurd
- Department of Bioengineering, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Isha Goel
- Department of Bioengineering, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Yasuyuki Sakai
- Department of Chemical System Engineering, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Yuji Teramura
- Cellular and Molecular Biotechnology Research Institute (CMB), National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba Central fifth, 1-1-1 Higashi, Tsukuba, Ibaraki, 305-8565, Japan
- Department of Immunology, Genetics and Pathology (IGP), Uppsala University, Dag Hammarskjölds väg 20, SE-751 85, Uppsala, Sweden
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Krishnan R, Mays W, Elijovich L. Complications of Mechanical Thrombectomy in Acute Ischemic Stroke. Neurology 2021; 97:S115-S125. [PMID: 34785610 DOI: 10.1212/wnl.0000000000012803] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 06/23/2021] [Indexed: 01/01/2023] Open
Abstract
Multiple randomized clinical trials have supported the use of mechanical thrombectomy (MT) as standard of care in the treatment of large vessel occlusion acute ischemic stroke. Optimal outcomes depend not only on early reperfusion therapy but also on post thrombectomy care. Early recognition of post MT complications including reperfusion hemorrhage, cerebral edema and large space occupying infarcts, and access site complications can guide early initiation of lifesaving therapies that can improve neurologic outcomes. Knowledge of common complications and their management is essential for stroke neurologists and critical care providers to ensure optimal outcomes. We present a review of the available literature evaluating the common complications in patients undergoing MT with emphasis on early recognition and management.
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Affiliation(s)
- Rashi Krishnan
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - William Mays
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Lucas Elijovich
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis.
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Gangadhara S, Siddiqui A, Mokin M. Food and Drug Association Approval Process for Devices Used in Endovascular Treatment of Stroke. Neurology 2021; 97:S194-S200. [PMID: 34785618 DOI: 10.1212/wnl.0000000000012804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article reviews the Food and Drug Administration's (FDA's) process for approval of new medical devices and describes the evolution of endovascular devices used for the treatment of acute ischemic stroke. RECENT FINDINGS Several recent studies have established the benefit of endovascular treatment of acute ischemic stroke from emergent large vessel occlusion. This has led to endovascular treatment becoming the usual care in acute stroke management and has generated greater-than-ever interest in the development of newer and more effective devices. SUMMARY In the United States, the FDA is the regulatory authority that is empowered with the approval and monitoring of new medical devices for widespread use in the population. The FDA categorizes medical devices into 3 classes based mainly on their potential risks to patients and/or users; class I devices pose the least risk and have the least stringent approval process, while class III devices pose the highest risk and undergo the most stringent and time-consuming approval process. There are 4 main pathways to approval: premarket notification, also known as the 510(k) pathway; premarket approval (PMA), de novo, and Humanitarian Device Exemption pathway. These pathways are described in detail in the article. The FDA also mandates postmarketing surveillance to identify any untoward and unexpected long-term complications.
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Affiliation(s)
- Shreyas Gangadhara
- From the Department of Neurology (S.G.), University of Mississippi Medical Center, Jackson; Department of Neurosurgery (A.S.), University at Buffalo, NY; and Department of Neurosurgery and Brain Repair (M.M.), University of South Florida, Tampa
| | - Adnan Siddiqui
- From the Department of Neurology (S.G.), University of Mississippi Medical Center, Jackson; Department of Neurosurgery (A.S.), University at Buffalo, NY; and Department of Neurosurgery and Brain Repair (M.M.), University of South Florida, Tampa
| | - Maxim Mokin
- From the Department of Neurology (S.G.), University of Mississippi Medical Center, Jackson; Department of Neurosurgery (A.S.), University at Buffalo, NY; and Department of Neurosurgery and Brain Repair (M.M.), University of South Florida, Tampa.
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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Sablot D, Farouil G, Leibinger F, Van Damme L, Aptel S, Fadat B, Tardieu M, Dutray A, Gascou G, Olivier N, Seiller I, Nguyen Them L, Smadja P, Ibanez-Julia MJ, Arquizan C, Mas J, Jurici S, Dumitrana A, Ferraro A, Costalat V, Bonafe L. Endovascular treatment for acute ischemic stroke at a primary stroke center: First results of the Perpignan center. Rev Neurol (Paris) 2021; 178:377-384. [PMID: 34556344 DOI: 10.1016/j.neurol.2021.05.006] [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: 01/18/2021] [Revised: 04/05/2021] [Accepted: 05/17/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Converting a high-volume primary stroke center (PSC) into a stroke center that can perform emergency endovascular treatment (EVT) could reduce the time to thrombectomy. We report the first results of a newly established EVT facility at the Perpignan PSC and their comparison with the targets defined by the established guidelines. PATIENTS AND METHOD For this comprehensive observational study, data of patients with acute ischemic stroke (AIS) due to proximal large vessel occlusion (LVO) and treated by EVT at the Perpignan PSC from December 5, 2019 to September 15, 2020 were extracted from an ongoing prospective database. RESULTS During the study period, 37 patients underwent EVT at the Perpignan PSC. The median (range) symptom-onset to recanalization time was 262min (100-485min). The median (range) intra-hospital times were: 20min (2-58min) for door-to-imaging, 57min (30-155min) for imaging-to-puncture, 55min (15-180min) for puncture-to-recanalization, and 137min (59-319min) for door-to-recanalization. At 3 months post-AIS, the favorable outcome (modified Ranking Score: 0-2) rate was 50% and the mortality rate was 19.4%. These results are comparable to those of previous clinical trials, and meet the targets defined by the current consensus statements for EVT. DISCUSSION AND CONCLUSION Our results show the feasibility and safety of EVT in a PSC for patients with AIS due to LVO. The implementation of this strategy may be important for shortening the time to thrombectomy.
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Affiliation(s)
- D Sablot
- Neurology Department, Perpignan hospital, Perpignan, France; Regional health agency of Occitanie, Montpellier, France.
| | - G Farouil
- Radiology Department, Perpignan hospital, Perpignan, France
| | - F Leibinger
- Intensive care unit, Perpignan hospital, Perpignan, France
| | - L Van Damme
- Neurology Department, Perpignan hospital, Perpignan, France
| | - S Aptel
- Radiology Department, Perpignan hospital, Perpignan, France
| | - B Fadat
- Neurology Department, Perpignan hospital, Perpignan, France
| | - M Tardieu
- Radiology Department, Perpignan hospital, Perpignan, France
| | - A Dutray
- Neurology Department, Perpignan hospital, Perpignan, France
| | - G Gascou
- Neuroradiology Department, University hospital of Montpellier, Montpellier, France
| | - N Olivier
- Neurology Department, Perpignan hospital, Perpignan, France
| | - I Seiller
- Radiology Department, Perpignan hospital, Perpignan, France
| | - L Nguyen Them
- Neurology Department, Perpignan hospital, Perpignan, France
| | - P Smadja
- Radiology Department, Perpignan hospital, Perpignan, France
| | | | - C Arquizan
- Neurology Department, University hospital of Montpellier, Montpellier, France
| | - J Mas
- Neurology Department, Perpignan hospital, Perpignan, France
| | - S Jurici
- Neurology Department, Perpignan hospital, Perpignan, France
| | - A Dumitrana
- Neurology Department, Perpignan hospital, Perpignan, France
| | - A Ferraro
- Neurology Department, Perpignan hospital, Perpignan, France
| | - V Costalat
- Neuroradiology Department, University hospital of Montpellier, Montpellier, France
| | - L Bonafe
- Radiology Department, Perpignan hospital, Perpignan, France; Neuroradiology Department, University hospital of Montpellier, Montpellier, France
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Chang WS, Li N, Liu H, Yin JJ, Zhang HQ. Thrombolysis and embolectomy in treatment of acute stroke as a bridge to open-heart resection of giant cardiac myxoma: A case report. World J Clin Cases 2021; 9:7572-7578. [PMID: 34616828 PMCID: PMC8464453 DOI: 10.12998/wjcc.v9.i25.7572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/24/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cardiac embolism is a common cause of ischemic stroke in young adults. Neurological complications associated with atrial myxoma most frequently include cerebral infarct due to embolus. Early complete resection of giant cardiac myxoma is the key to its treatment and prevention of stroke recurrence.
CASE SUMMARY A 42-year-old, previously healthy woman was admitted to the hospital with sudden-onset inability to speak and right-sided hemiplegia. While sweeping the floor 2 h prior to hospital admission, the patient developed sudden inability to express herself or understand what others were saying, accompanied by dyskinesia of the right limb, inability to walk or hold objects, and involuntary choreiform movements of the left upper limb. The patient was diagnosed with cerebral embolism and cardiac myxoma, complicated by left middle cerebral artery occlusion. The acute stroke was treated with intravenous thrombolytic therapy and arterial embolectomy as a bridging therapy to open resection of left atrial cardiac myxoma. The patient condition improved remarkably following initial thrombolysis and embolectomy and subsequently underwent emergency open resection of the atrial cardiac myxoma. She had no recurrence during 1-year follow-up.
CONCLUSION Strong consideration should be given to urgent intravenous thrombolysis (rt-PA, alteplase) in young adult stroke patients at the time of hospital admission. The present case demonstrated a highly successful outcome that combined thrombolysis and arterial embolus retrieval as a bridge to early complete resection of a giant cardiac myxoma for both stroke treatment and recurrence prevention.
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Affiliation(s)
- Wan-Sheng Chang
- Department of Neurology, The Second People's Hospital of Liaocheng City, The Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Linqing 252600, Shandong Province, China
| | - Na Li
- Department of Neurology, The Second People's Hospital of Liaocheng City, The Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Linqing 252600, Shandong Province, China
| | - Hui Liu
- Department of Neurology, The Second People's Hospital of Liaocheng City, The Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Linqing 252600, Shandong Province, China
| | - Ji-Jun Yin
- Department of Neurology, The Second People's Hospital of Liaocheng City, The Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Linqing 252600, Shandong Province, China
| | - Hai-Qi Zhang
- Department of Neurology, The Second People's Hospital of Liaocheng City, The Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Linqing 252600, Shandong Province, China
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Shiraz Bhurwani MM, Snyder KV, Waqas M, Mokin M, Rava RA, Podgorsak AR, Chin F, Davies JM, Levy EI, Siddiqui AH, Ionita CN. Use of quantitative angiographic methods with a data-driven model to evaluate reperfusion status (mTICI) during thrombectomy. Neuroradiology 2021; 63:1429-1439. [PMID: 33415348 PMCID: PMC8409249 DOI: 10.1007/s00234-020-02598-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Intra-procedural assessment of reperfusion during mechanical thrombectomy (MT) for emergent large vessel occlusion (LVO) stroke is traditionally based on subjective evaluation of digital subtraction angiography (DSA). However, semi-quantitative diagnostic tools which encode hemodynamic properties in DSAs, such as angiographic parametric imaging (API), exist and may be used for evaluation of reperfusion during MT. The objective of this study was to use data-driven approaches, such as convolutional neural networks (CNNs) with API maps, to automatically assess reperfusion in the neuro-vasculature during MT procedures based on the modified thrombolysis in cerebral infarction (mTICI) scale. METHODS DSAs from patients undergoing MTs of anterior circulation LVOs were collected, temporally cropped to isolate late arterial and capillary phases, and quantified using API peak height (PH) maps. PH maps were normalized to reduce injection variability. A CNN was developed, trained, and tested to classify PH maps into 2 outcomes (mTICI 0,1,2a/mTICI 2b,2c,3) or 3 outcomes (mTICI 0,1,2a/mTICI 2b/mTICI 2c,3), respectively. Ensembled networks were used to combine information from multiple views (anteroposterior and lateral). RESULTS The study included 383 DSAs. For the 2-outcome classification, average accuracy was 81.0% (95% CI, 79.0-82.9%), and the area under the receiver operating characteristic curve (AUROC) was 0.86 (0.84-0.88). For the 3-outcome classification, average accuracy was 64.0% (62.0-66.0), and AUROC values were 0.85 (0.83-0.87), 0.74 (0.71-0.77), and 0.78 (0.76-0.81) for the mTICI 0,1,2a, mTICI 2b, and mTICI 2c,3 classes, respectively. CONCLUSION This study demonstrated the feasibility of using hemodynamic information in API maps with data-driven models to autonomously assess intra-procedural reperfusion during MT.
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Affiliation(s)
- Mohammad Mahdi Shiraz Bhurwani
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, 14228, USA
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
| | - Kenneth V Snyder
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, 33606, USA
| | - Ryan A Rava
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, 14228, USA
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
| | - Alexander R Podgorsak
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, 14228, USA
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
| | - Felix Chin
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Jason M Davies
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, 14228, USA.
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA.
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA.
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Hassan AE, Dibas M, Sarraj A, Ghozy S, El-Qushayri AE, Dmytriw AA, Tekle WG. First pass effect vs multiple passes complete reperfusion: A retrospective study. Neuroradiol J 2021; 35:306-312. [PMID: 34464222 DOI: 10.1177/19714009211042886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE First pass effect (FPE) is defined as achieving modified treatment in cerebral infarction (mTICI) grade 2c/3 reperfusion from the first pass and is associated with more favorable outcomes. We aimed to compare FPE and non-FPE using a large database and further compare first-pass mTICI 2b with multiple passes mTICI 3. METHODS A retrospective cohort study of acute ischemic stroke patients who received mechanical thrombectomy at a high-volume center was performed. Baseline characteristics and outcomes including rates of discharge and 90-day functional independence (modified Rankin Scale ≤2), mortality, symptomatic, and asymptomatic intracerebral hemorrhage were compared. RESULTS Of the 637 patients included, 294 achieved FPE; 161 patients had multiple passes mTICI 3 and 36 had first pass mTICI 2b. Propensity-score matching resulted in 211 matched pairs for FPE vs non-FPE, and 30 matched pairs for multiple passes mTICI 3 vs first pass mTICI 2b. The FPE group had significantly more instances of discharge (33.6% vs 19.4%, p = 0.001) and 90-day functional independence (51.7% vs 40.8%, p = 0.032), and lower rates of mortality (18.0% vs 27.5%, p = 0.027) compared to non-FPE. There was no significant difference between first pass mTICI 2b and multiple passes mTICI 3 concerning any studied outcomes. CONCLUSIONS First pass mTICI 2c/3 is safer and is associated with higher rates of functional independence. We did not observe a significant difference between first pass mTICI 2b and multiple passes mTICI 3. The limitations of this study prevent us from drawing conclusions related to the difference between them and calls for future large-scale studies to explore that further.
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Affiliation(s)
- Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center - Harlingen, TX, USA
| | - Mahmoud Dibas
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center - Harlingen, TX, USA.,Sulaiman Al Rajhi University, College of Medicine, Saudi Arabia
| | - Amrou Sarraj
- Department of Neurology, University of Texas at Houston Stroke Center, Houston, TX, USA
| | - Sherief Ghozy
- Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Neurosurgery Department, El Sheikh Zayed Specialized Hospital, Giza, Egypt
| | | | - Adam A Dmytriw
- Neuroradiology and Neurointervention Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wondwossen G Tekle
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center - Harlingen, TX, USA
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Hung MY, Yang CK, Chen JH, Lin LH, Hsiao HM. Novel Blood Clot Retriever for Ischemic Stroke. MICROMACHINES 2021; 12:mi12080928. [PMID: 34442550 PMCID: PMC8398896 DOI: 10.3390/mi12080928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 11/23/2022]
Abstract
Stroke is the second leading cause of death in the world. Ischemic stroke, caused by the blockage of intracranial arteries, accounts for approximately 80% of strokes. Among this proportion, acute ischemic stroke, usually caused by the sudden formation of blood clots, can cause fatal blockages in arteries. We proposed a unique blood clot retriever for the treatment of acute ischemic stroke, and conducted a series of tasks, including design, computer simulation, prototyping, and bench testing, for the proof of concept. Unlike most blood clot retrievers used today, our novel design deviates from traditional stent-like blood clot retrievers and uses large closed cells, irregular spikes, and strut protrusions to achieve maximum entanglement for better retrieval performance. Experimental results showed that the retrieval rate of our blood clot retriever was 79%, which demonstrated the feasibility of our new design concept.
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Abe T, Olanipekun T, Igwe J, Khoury M, Busari O, Musonge-Effoe J, Valery E, Egbuche O, Mather P, Ghali J. Trends, Predictors and Outcomes of Ischemic Stroke Among Patients Hospitalized with Takotsubo Cardiomyopathy. J Stroke Cerebrovasc Dis 2021; 30:106005. [PMID: 34332228 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106005] [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: 05/27/2021] [Revised: 07/04/2021] [Accepted: 07/09/2021] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES This study assessed the temporal trends in the incidence of ischemic stroke among patients hospitalized with takotsubo cardiomyopathy (TCM) stratified by the subtypes of ischemic stroke (cardioembolic versus thrombotic). Predictors of each stroke subtype, the association with atrial fibrillation (AF), the occurrence of ventricular fibrillation/ventricular tachycardia (VF/VT), cardiogenic shock (CS), in-hospital mortality, length of stay (LOS), and total healthcare cost were also assessed. BACKGROUND Ischemic stroke in TCM is thought to be primarily cardioembolic from left ventricular mural thromboembolism. Limited data are available on the incidence of thrombotic ischemic stroke in TCM. MATERIALS AND METHODS We identified 27,970 patients hospitalized with the primary diagnosis of TCM from the 2008 to 2017 National Inpatient Sample, of which 751 (3%) developed ischemic stroke. Of those with ischemic stroke, 571 (76%) had thrombotic stroke while 180 (24%) had cardioembolic stroke. Cochrane armitage test was used to assess the incidence of thrombotic and cardioembolic strokes and multivariate regression was used to identify risk factors associated with each stroke subtype. We compared the incidence of AF, VF/VT, CS, LOS, in-hospital mortality and total cost between hospitalized patients with TCM alone to those with cardioembolic and thrombotic strokes. RESULTS From 2008 - 2017, the incidence of thrombotic stroke (4.7%-9.5% (p< 0.0001) increased while it was unchanged for cardioembolic stroke (0.5%-0.7% P=0.5). In the multivariate regression, peripheral artery disease, prior history of stroke, and hyperlipidemia were significantly associated with thrombotic stroke, while CS, AF, and Asian race (compared to White race) were associated with cardioembolic stroke. Both cardioembolic and thrombotic strokes were associated with higher odds of IHM, AF, CS, longer LOS and increased cost. Trends in in-hospital mortality and the utilization of thrombolysis, cerebral angiography, and mechanical thrombectomy among patients with TCM and ischemic stroke were unchanged from 2008 to 2017. CONCLUSION Among patients with TCM and ischemic stroke, thrombotic stroke was more common compared to cardioembolic stroke. Ischemic stroke was associated with poorer outcomes, including higher in-hospital mortality and increased healthcare resource utilization in TCM.
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Affiliation(s)
- Temidayo Abe
- Department of Medicine, Morehouse School of Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, United States.
| | - Titilope Olanipekun
- Department of Medicine, Morehouse School of Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, United States.
| | - Joseph Igwe
- Department of Medicine, Morehouse School of Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, United States.
| | - Mtanis Khoury
- Department of Medicine, Mount Sinai Hospital, 1500 S California Ave, Chicago, IL 60608, United States.
| | - Olukayode Busari
- Department of Medicine, Coney Island Hospital, 2601 Ocean Pkway, Brooklyn, NY 11235, United States.
| | - Joffi Musonge-Effoe
- Department of Community and Preventive Medicine, Morehouse School of Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, United States.
| | - Effoe Valery
- Department of Cardiovascular Disease, Morehouse School of Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, United States.
| | - Obiora Egbuche
- Department of Cardiovascular Disease, Morehouse School of Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, United States.
| | - Paul Mather
- Department of Cardiovascular Disease, Perelman School of Medicine, 2 East Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States.
| | - Jalal Ghali
- Department of Medicine, Morehouse School of Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, United States.
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43
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Arturo Larco J, Abbasi M, Liu Y, Madhani SI, Shahid AH, Kadirvel R, Brinjikji W, Savastano LE. Per-pass analysis of recanalization and good neurological outcome in thrombectomy for stroke: Systematic review and meta-analysis. Interv Neuroradiol 2021; 28:358-363. [PMID: 34229523 DOI: 10.1177/15910199211028342] [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: 12/22/2022] Open
Abstract
BACKGROUND AND AIM First pass effect (FPE) is defined as achieving a complete recanalization with a single thrombectomy device pass. Although clinically desired, FPE is reached in less than 30% of thrombectomy procedures. Multiple device passes are often necessary to achieve successful or complete recanalization. We performed a systematic review and meta-analysis to determine the recanalization rate after each pass of mechanical thrombectomy and its association with good neurological outcome. METHODS A literature search was performed for studies reporting the number of device passes required for either successful (mTICI 2b or higher) or complete (mTICI 2c or higher) recanalization. Using random-effect meta-analysis, we evaluated the likelihood of recanalization and good neurological outcome (measured with the modified Rankin Score <2 at 90 days) after each device pass. RESULTS Thirteen studies comprising 4197 patients were included. Among cases with failed first pass, 24% of them achieved final complete recanalization and 45% of them achieved final successful recanalization. Independently to the total number of previously failed attempts, the likelihood of achieving successful recanalization was 30% per pass, and the likelihood to achieve complete recanalization was about 20% per pass. The likelihood of good neurological outcome in patients with final successful recanalization decreased after each device pass: 55% after the first pass, 48% after the second pass, 42% after the third pass, 36% after the fourth pass, and 26% for 5 passes or more. CONCLUSION Each pass is associated with a stable likelihood of recanalization but a decreased likelihood of good neurological outcome.
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Affiliation(s)
| | - Mehdi Abbasi
- Department of Neurosurgery, Mayo Clinic, Rochester, USA.,Department of Radiology, Mayo Clinic, Rochester, USA
| | - Yang Liu
- Department of Neurosurgery, Mayo Clinic, Rochester, USA.,Department of Radiology, Mayo Clinic, Rochester, USA
| | | | | | | | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, Rochester, USA.,Department of Radiology, Mayo Clinic, Rochester, USA
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Yeo LLL, Chen VHE, Leow AST, Meyer L, Fiehler J, Tu TM, Tham CH, Sia CH, Jamous A, Behme D, Kastrup A, Papanagiotou P, Styczen H, Forsting M, Lee TH, Chu CL, Fischer S, Maus V, Abdullayev N, Kabbasch C, Mönch S, Maegerlein C, Arnberg F, Andersson T, Holmin S, Teoh HL, Paliwal P, Ahmad A, Gopinathan A, Yang C, Seet RCS, Chan BPL, Sharma VK, Tan BYQ. Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: A real-world multicenter experience. Eur J Neurol 2021; 28:2736-2744. [PMID: 33960072 DOI: 10.1111/ene.14899] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022]
Abstract
Endovascular thrombectomy (EVT) is the standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO). Young patients with AIS-LVO have distinctly different underlying stroke mechanisms and etiologies. Much is unknown about the safety and efficacy of EVT in this population of young AIS-LVO patients. All consecutive AIS-LVO patients aged 50 years and below were included in this multicenter cohort study. The primary outcome measured was functional recovery at 90 days, with modified Rankin Scale of 0-2 deemed as good functional outcome. A total of 275 AIS-LVO patients that underwent EVT from 10 tertiary centers in Germany, Sweden, Singapore, and Taiwan were included. Successful reperfusion was achieved in 85.1% (234/275). Good functional outcomes were achieved in 66.0% (182/275). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%). National Institutes of Health Stroke Scale (NIHSS) score at presentation was inversely related to good functional outcomes (aOR: 0.92, 95% CI: 0.88-0.96 per point increase, p < 0.001). Successful reperfusion (aOR: 3.22, 95% CI: 1.44-7.21, p = 0.005), higher ASPECTS (aOR: 1.21, 95% CI: 1.01-1.44, p = 0.036), and bridging intravenous thrombolysis (aOR: 2.37, 95% CI: 1.29-4.34, p = 0.005) independently predicted good functional outcomes. Successful reperfusion was inversely associated with in-hospital mortality (aOR: 0.14, 95% CI: 0.03-0.57, p = 0.006). History of hypertension strongly predicted in-hospital mortality (aOR: 4.59, 95% CI: 1.10-19.13, p = 0.036). While differences in functional outcomes exist across varying stroke aetiologies, high rates of successful reperfusion and good outcomes are generally achieved in young AIS-LVO patients undergoing EVT.
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Affiliation(s)
- Leonard Leong-Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vanessa Hui En Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Aloysius Sheng-Ting Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tian-Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore City, Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, Singapore City, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Center, Singapore City, Singapore
| | - Ala Jamous
- Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Daniel Behme
- Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany.,Areteion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Hanna Styczen
- Institute of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Tsong-Hai Lee
- Stroke Section, Department of Neurology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chan-Lin Chu
- Stroke Section, Department of Neurology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Sebastian Fischer
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Bochum-Langendreer, Bochum, Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Bochum-Langendreer, Bochum, Germany
| | - Nuran Abdullayev
- Institute of Radiology and Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Institute of Radiology and Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hock-Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Prakash Paliwal
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Aftab Ahmad
- Division of Neurology, Ng Teng Fong Hospital, Singapore City, Singapore
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
| | - Raymond Chee-Seong Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Bernard Poon-Lap Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
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45
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Abstract
Worldwide cardiovascular diseases such as stroke and heart disease are the leading cause of mortality. While guidewire/catheter-based minimally invasive surgery is used to treat a variety of cardiovascular disorders, existing passive guidewires and catheters suffer from several limitations such as low steerability and vessel access through complex geometry of vasculatures and imaging-related accumulation of radiation to both patients and operating surgeons. To address these limitations, magnetic soft continuum robots (MSCRs) in the form of magnetic field-controllable elastomeric fibers have recently demonstrated enhanced steerability under remotely applied magnetic fields. While the steerability of an MSCR largely relies on its workspace-the set of attainable points by its end effector-existing MSCRs based on embedding permanent magnets or uniformly dispersing magnetic particles in polymer matrices still cannot give optimal workspaces. The design and optimization of MSCRs have been challenging because of the lack of efficient tools. Here, we report a systematic set of model-based evolutionary design, fabrication, and experimental validation of an MSCR with a counterintuitive nonuniform distribution of magnetic particles to achieve an unprecedented workspace. The proposed MSCR design is enabled by integrating a theoretical model and the genetic algorithm. The current work not only achieves the optimal workspace for MSCRs but also provides a powerful tool for the efficient design and optimization of future magnetic soft robots and actuators.
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46
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Hoque MM, Abdelazim H, Jenkins-Houk C, Wright D, Patel BM, Chappell JC. The cerebral microvasculature: Basic and clinical perspectives on stroke and glioma. Microcirculation 2021; 28:e12671. [PMID: 33171539 PMCID: PMC11064683 DOI: 10.1111/micc.12671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/13/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022]
Abstract
Microvascular networks are vital components of the cardiovascular system, performing many key roles in maintaining the health and homeostasis of the tissues and organs in which they develop. As discussed in this review, the molecular and cellular components within the microcirculation orchestrate critical processes to establish functional capillary beds, including organization of endothelial cell (EC) polarity, guiding investment of vascular pericytes (PCs), and building the specialized extracellular matrix (ECM) that comprises the vascular basement membrane (vBM). Herein, we further discuss the unique features of the microvasculature in the central nervous system (CNS), focusing on the cells contributing to the neurovascular unit (NVU) that form and maintain the blood-brain barrier (BBB). With a focus on vascular PCs, we offer basic and clinical perspectives on neurovascular-related pathologies that involve defects within the cerebral microvasculature. Specifically, we present microvascular anomalies associated with glioblastoma multiforme (GBM) including defects in vascular-immune cell interactions and associated clinical therapies targeting microvessels (ie, vascular-disrupting/anti-angiogenic agents and focused ultrasound). We also discuss the involvement of the microcirculation in stroke responses and potential therapeutic approaches. Our goal was to compare the cellular and molecular changes that occur in the microvasculature and NVU, and to provide a commentary on factors driving disease progression in GBM and stroke. We conclude with a forward-looking perspective on the importance of microcirculation research in developing clinical treatments for these devastating conditions.
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Affiliation(s)
- Maruf M. Hoque
- Center for Heart and Reparative Medicine Research, Fralin Biomedical Research Institute at Virginia Tech-Carilion, Roanoke, VA 24016, USA
- Graduate Program in Translational Biology, Medicine and Health, Virginia Tech, Blacksburg, VA 24061, USA
| | - Hanaa Abdelazim
- Center for Heart and Reparative Medicine Research, Fralin Biomedical Research Institute at Virginia Tech-Carilion, Roanoke, VA 24016, USA
- Graduate Program in Translational Biology, Medicine and Health, Virginia Tech, Blacksburg, VA 24061, USA
| | | | - Dawn Wright
- Virginia Tech Carilion School of Medicine, Roanoke, VA, 24016, USA
| | - Biraj M. Patel
- Virginia Tech Carilion School of Medicine, Roanoke, VA, 24016, USA
- Department of Radiology, Carilion Clinic, Roanoke, VA, 24016, USA
| | - John C. Chappell
- Center for Heart and Reparative Medicine Research, Fralin Biomedical Research Institute at Virginia Tech-Carilion, Roanoke, VA 24016, USA
- Virginia Tech Carilion School of Medicine, Roanoke, VA, 24016, USA
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA 24061, USA
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47
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Pego Pérez ER, Fernández I, Pumar JM. Functional outcomes of patients with stroke treated with thrombectomy by aspiration. Brain Inj 2021; 35:476-483. [PMID: 33635736 DOI: 10.1080/02699052.2021.1887519] [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: 10/22/2022]
Abstract
Purpose: To determine the time of procedure, the value of modified Thrombolysis in Cerebral Infarction and National Institute Health of Stroke Scale as predictors of the functional results of patients with stroke treated with mechanical thrombectomy by aspiration.Methods: Observational, analytical, and retrospective case series analysis of consecutive patients with internal carotid and cerebral media branch occlusions. Clinical outcome was measured with the modified Rankin Scale at 90 days after stroke. To analyze the differences between groups, the Chi2 test was used for the qualitative variables.Results: The sample size was 58 patients treated with thrombectomy by aspiration. We observed that the thrombectomy time determines the recanalization results; meanwhile, modified Thrombolysis in Cerebral Infarction is a predictor of modified Rankin Scale at discharge but not after 3 months. National Institute Health of Stroke Scale was determinant for modified Rankin Scale result.Conclusions: Mechanical thrombectomy by aspiration proves to be an effective treatment of acute stroke, improving the patient's vital and functional prognosis. The thrombectomy time is a predictor of the result in relation to the degree of recanalization determined by the modified Thrombolysis in Cerebral Ischemia. Also, the degree of recanalization predicts functional outcome at discharge but not at 3 months.
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Affiliation(s)
- E Rubén Pego Pérez
- Department of Psychiatry, Radiology, Public Health, Nursing and Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Isaac Fernández
- Department of Psychiatry, Radiology, Public Health, Medicine and Nursing-External, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - J Manuel Pumar
- Department of Psychiatry, Radiology, Public Health, Nursing and Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
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Yamagami H, Hayakawa M, Inoue M, Iihara K, Ogasawara K, Toyoda K, Hasegawa Y, Ohata K, Shiokawa Y, Nozaki K, Ezura M, Iwama T. Guidelines for Mechanical Thrombectomy in Japan, the Fourth Edition, March 2020: A Guideline from the Japan Stroke Society, the Japan Neurosurgical Society, and the Japanese Society for Neuroendovascular Therapy. Neurol Med Chir (Tokyo) 2021; 61:163-192. [PMID: 33583863 DOI: 10.2176/nmc.nmc.st.2020-0357] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Manabu Inoue
- Division of Stroke Care Unit/Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.,Stroke Center and Department of Neurology, Shin-yurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | | | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
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49
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Waqas M, Gong AD, Levy BR, Dossani RH, Vakharia K, Cappuzzo JM, Becker A, Sonig A, Tutino VM, Almayman F, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:105557. [PMID: 33556672 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Bennett R Levy
- George Washington School of Medicine and Health Sciences, Washington, DC, USA.
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Alexander Becker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA; Department of Pathology and Anatomical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
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Gottula AL, Barreto AD, Adeoye O. Alteplase and Adjuvant Therapies for Acute Ischemic Stroke. Semin Neurol 2021; 41:16-27. [PMID: 33472270 DOI: 10.1055/s-0040-1722720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Acute ischemic stroke (AIS) is a time sensitive medical emergency and a leading cause of morbidity and mortality worldwide. Intravenous (IV) recombinant tissue plasminogen activator (IV alteplase) is currently the only proven effective medication for the treatment of AIS with promising adjuvant medications currently under investigation. Recent advances in endovascular thrombectomy have broadened therapeutic options in specific patient populations, with modern treatment strategies utilizing advanced imaging modalities to extend the window for treatment. In all cases, rapid treatment remains a priority. The future of IV alteplase and the changing standard for treatment of AIS remain unwritten with the increasing evidence for imaging selection for both endovascular thrombectomy and IV alteplase, while novel adjuncts are under investigation. In this article, we review the history of IV alteplase investigations for stroke, evidence for thrombectomy as an adjunct to IV alteplase, and the potential of novel adjuvant therapeutics currently under investigation.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Andrew D Barreto
- Department of Neurology, University of Texas Houston, Houston, Texas
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
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