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dos Santos Neto EP, de Sousa ÍA, Veras ADO, de Barros-Araújo ML, Ricarte IF, Pontes-Neto OM. Case report: Flow changes in routes of collateral circulation in patients with LVO and low NIHSS: a point favor to treat. Front Neurol 2023; 14:1165484. [PMID: 37360333 PMCID: PMC10287161 DOI: 10.3389/fneur.2023.1165484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/08/2023] [Indexed: 06/28/2023] Open
Abstract
The effectiveness of endovascular thrombectomy in patients presenting low National Institutes of Health Stroke Scale (NIHSS) scores remains controversial, and the acquisition of additional evidence is required to refine the selection of candidates who may benefit the most from this therapeutic modality. In this study, we present the case of a 62-year-old individual, with left internal carotid occlusion stroke and low NIHSS, who had compensatory collateral flow from Willis polygon via the anterior communicating artery. The patient subsequently exhibited neurological deterioration and collateral flow failure from Willis polygon, indicating the need for urgent intervention. The study of collaterals in patients with large vessel occlusion stroke has garnered considerable attention, with research suggesting that individuals with low NIHSS scores and poor collateral profiles may be at a heightened risk of early neurological deterioration. We postulate that such patients may derive significant benefits from endovascular thrombectomy, and may posit that an intensive transcranial Doppler monitoring protocol could facilitate the identification of suitable candidates for such intervention.
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Affiliation(s)
- Elizeu Pereira dos Santos Neto
- Institute of Radiology, University of São Paulo School of Medicine, Hospital das Clínicas, São Paulo, SP, Brazil
- Neurologist and Interventional Neuroradiologist, Hospital Santa Maria, Teresina, PI, Brazil
| | - Ícaro Araújo de Sousa
- Department of Neuroscience and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Arthur de Oliveira Veras
- Department of Neuroscience and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Marx Lima de Barros-Araújo
- Institute of Radiology, University of São Paulo School of Medicine, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Irapuá Ferreira Ricarte
- Department of Neurology and Neurosurgery, São Paulo Federal University, São Paulo, SP, Brazil
| | - Octávio Marques Pontes-Neto
- Department of Neuroscience and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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Venketasubramanian N, Pokharkar Y, Chai JH, Chen CLH. Ischemic Stroke and Savings in Time to Achieve Functional Recovery: Experience from NeuroAiD. J Cardiovasc Dev Dis 2023; 10:jcdd10030117. [PMID: 36975881 PMCID: PMC10059584 DOI: 10.3390/jcdd10030117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/23/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Despite recent progress with revascularisation interventions after acute ischemic stroke, many patients remain disabled after stroke. Using data from a multi-centre, randomised, double-blind, placebo-controlled trial of a neuro-repair treatment (NeuroAiD/MLC601) with a long-term follow-up, we analysed the savings in time to functional recovery, measured by a modified Rankin Scale (mRS) score of 0 or 1, in patients receiving a 3-month oral course of MLC601. Analysis of time to recovery was assessed by a log-rank test and hazard ratios (HRs) adjusted for prognosis factors. A total of 548 patients with baseline NIHSS scores 8–14, mRS scores ≥ 2 at day 10 post-stroke, and at least one mRS assessment on or after month 1 were included in the analysis (placebo = 261; MLC601 = 287). Time to functional recovery was significantly shortened for patients receiving MLC601 versus patients receiving placebo (log-rank test: p = 0.039). This result was confirmed by Cox regression adjusting for the main baseline prognostic factors (HR: 1.30 [0.99, 1.70]; p = 0.059) and was more pronounced in patients with additional poor prognosis factors. The Kaplan–Meier plot showed that approximately 40% cumulative incidence of functional recovery was achieved within 6 months after stroke onset in the MLC601 group versus 24 months in the placebo group. The main findings are that MLC601 reduced the time to achieve functional recovery, and a 40% functional recovery rate was achieved 18 months earlier compared to placebo.
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Affiliation(s)
| | - Yogesh Pokharkar
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation Singapore, 23 Rochester Park, Singapore 139234, Singapore
| | - Jia Hui Chai
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation Singapore, 23 Rochester Park, Singapore 139234, Singapore
| | - Christopher Li Hsian Chen
- Memory Aging and Cognition Centre, Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117600, Singapore
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Outcomes after endovascular mechanical thrombectomy for low compared to high National Institutes of Health Stroke Scale (NIHSS): A multicenter study. Clin Neurol Neurosurg 2023; 225:107592. [PMID: 36657358 DOI: 10.1016/j.clineuro.2023.107592] [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: 09/19/2022] [Revised: 01/02/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The role of endovascular mechanical thrombectomy (MT) in patients presenting with "minor" stroke is uncertain. We aimed to compare outcomes after MT for ischemic stroke patients presenting with National Institutes of Health Stroke Scale (NIHSS) 5 and - within the low NIHSS cohort - identify predictors of a favorable outcome, mortality, and symptomatic intracranial hemorrhage (ICH). METHODS We retrospectively analyzed a prospectively maintained, international, multicenter database. RESULTS The study cohort comprised a total of 7568 patients from 29 centers. NIHSS was low (<5) in 604 patients (8%), and > 5 in 6964 (92%). Patients with low NIHSS were younger (67 + 14.8 versus 69.6 + 14.7 years, p < 0.001), more likely to have diabetes (31.5% versus 26.9%, p = 0.016), and less likely to have atrial fibrillation (26.6% versus 37.6%, p < 0.001) compared to those with higher NIHSS. Radiographic outcomes (TICI > 2B 84.6% and 84.3%, p = 0.412) and complication rates (8.1% and 7.2%, p = 0.463) were similar between the low and high NIHSS groups, respectively. Clinical outcomes at every follow up interval, including NIHSS at 24 h and discharge, and mRS at discharge and 90 days, were better in the low NIHSS group, however patients in the low NIHSS group experienced a relative decline in NIHSS from admit to discharge. Mortality was lower in the low NIHSS group (10.4% versus 24.5%, p < 0.001). CONCLUSIONS Relative to patients with high NIHSS, MT is safe and effective for stroke patients with low NIHSS, and it is reasonable to offer it to appropriately selected patients presenting with minor stroke symptoms. Our findings justify efforts towards a randomized trial comparing MT versus medical management for patients with low NIHSS.
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Yedavalli VS, Hamam O, Gudenkauf J, Wang R, Llinas R, Marsh EB, Caplan J, Nael K, Urrutia V. Assessing the Efficacy of Mechanical Thrombectomy in Patients with an NIHSS < 6 Presenting with Proximal Middle Cerebral Artery Vessel Occlusion as Compared to Best Medical Management. Brain Sci 2023; 13:brainsci13020214. [PMID: 36831757 PMCID: PMC9953866 DOI: 10.3390/brainsci13020214] [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: 01/13/2023] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Minor acute ischemic stroke (AIS) patients-defined by an NIHSS score < 6-presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have shown that several patients afflicted with MCA-LVO in this subgroup experience cognitive and functional decline. Although mechanical thrombectomy (MT) is the standard of care for patients with an NIHSS score of 6 or higher, treatment in the minor stroke subgroup is still being explored. The purpose of this preliminary study is to report our center's experience in evaluating the potential benefit of mechanical thrombectomy (MT) in minor stroke patients when compared to medical management (MM). METHODS We performed a retrospective study with two comprehensive stroke centers within our hospital enterprise of consecutive patients presenting with minor AIS secondary to MCA-LVO (defined as M1 or proximal M2 segments of MCA). We subsequently evaluated patients who received MT versus those who received MM. RESULTS Between January 2017 and July 2021, we identified 46 AIS patients (11 treated with MT and 35 treated with MM) who presented with an NIHSS score < 6 secondary to MCA-LVO (47.8% 22/46 female, mean age 62.3 years, range 49-75 years). MT was associated with a significantly lower mRS at 90 days (median: 1.0 [IQR 0.0-2.0] versus 3.0 [IQR 1.0-4.0], p = <0.001), a favorable NIHSS shift (-4.0 [IQR -10.0--2.0] versus 0.0 [IQR -2.0-1.0], p = 0.002), favorable NIHSS shift dichotomization (5/11, 45.5% versus 3/35, 8.6%, p = 0.003) and favorable mRS dichotomization (7/11, 63.6% versus 14/35, 40.0%, p = 0.024). CONCLUSIONS In our center's preliminary experience, for AIS patients presenting with an NIHSS score < 6 secondary to MCA-LVO, MT may be associated with improved clinical outcomes when compared to MM only.
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Affiliation(s)
- Vivek Srikar Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, 600 N Wolfe Street, Baltimore, MD 21287, USA
| | - Omar Hamam
- Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD 21205, USA
| | - Julie Gudenkauf
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD 21205, USA
| | - Rafael Llinas
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Elisabeth Breese Marsh
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Justin Caplan
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Kambiz Nael
- Department of Radiology, University of California, Los Angeles, CA 90095, USA
| | - Victor Urrutia
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
- Correspondence:
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Ouyang M, Shajahan S, Liu X, Sun L, Carcel C, Harris K, Anderson CS, Woodward M, Wang X. Sex differences in the utilization and outcomes of endovascular treatment after acute ischemic stroke: A systematic review and meta-analysis. Front Glob Womens Health 2023; 3:1032592. [PMID: 36741299 PMCID: PMC9889638 DOI: 10.3389/fgwh.2022.1032592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/22/2022] [Indexed: 01/20/2023] Open
Abstract
Background Studies of sex differences in the use and outcomes of endovascular treatment (EVT) for acute ischemic stroke report inconsistent results. Methods We systematically searched PubMed and Embase databases for studies examining sex-specific utilization of EVT for acute ischemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT use. To estimate sex differences in functional outcome on the modified Rankin scale after EVT, the female:male ratio of ORs and 95% confidence intervals (CIs) were obtained from ordinal or binary analysis. Results 6,396 studies were identified through database searching, of which 594 qualified for a full review. A total of 51 studies (36 non-RCT and 15 RCTs) reporting on sex-specific utilization of EVT were included, and of those 10 estimated the sex differences of EVT on functional outcomes. EVT use was similar in women and men both in non-RCTs (OR: 1.03, 95% CI: 0.96-1.11) and RCTs (1.02, 95% CI: 0.89-1.16), with consistent results across years of publication and regions of study, except that in Europe EVT treatment was higher in women than men (1.15, 95% CI: 1.13-1.16). No sex differences were found in the functional outcome by either ordinal and binary analyses (ORs 0.95, 95% CI: 0.68-1.32] and 0.90, 95% CI: 0.65-1.25, respectively). Conclusions No sex differences in EVT utilization or on functional outcomes were evident after acute ischemic stroke from large-vessel occlusion. Further research may be required to examine sex differences in long-term outcomes, social domains, and quality of life. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=226100, identifier: CRD42021226100.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Sultana Shajahan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Liu
- Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Lingli Sun
- Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Katie Harris
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Correspondence: Xia Wang
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Wang Z, Wang S, Li Y, Wang R, Jiang L, Zheng B, Zhang Y, Wang Q, Wang J. Biomarker of early neurological deterioration in minor stroke and proximal large vessel occlusion: A pilot study. Front Neurol 2022; 13:1019530. [PMID: 36388185 PMCID: PMC9642090 DOI: 10.3389/fneur.2022.1019530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/05/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Plasma neurofilament light chain (pNFL) represents one of the scaffolding proteins of central nervous system axonal injury. The aim of this study was to evaluate pNFL as a predictive biomarker for early neurological deterioration (END) in medically managed patients with large vessel occlusion (LVO) and mild presentation (NIHSS < 6). METHODS This retrospective study was developed from a prospectively collected stroke database, which was conducted at a large academic comprehensive stroke center in western China. Patients who first presented with acute ischemic stroke (AIS) within 24 h of symptom onset were continuously included. Stroke severity was analyzed at admission using the NIHSS score. The pNFL drawn on admission was analyzed with a novel ultrasensitive single-molecule array. RESULTS Thirty-nine consecutive patients were included in the analysis, and 19 (48.72%) patients experienced END. Patients who experienced END had significantly higher pNFL levels (mean, 65.20 vs. 48.28 pg/mL; P < 0.001) and larger infarct volume (mean, 15.46 vs. 9.56 mL; P < 0.001). pNFL was valuable for the prediction of END (OR, 1.170; 95% CI, 1.049-1.306; P = 0.005), even after adjusted for age and sex (OR, 1.178; 95% CI, 1.038-1.323; P = 0.006), blood sampling time, baseline NIHSS, TOAST classification, and infarct volume (OR, 1.168; 95% CI, 1.034-1.320; P = 0.012). The area under the ROC curve was 85.0% (95% CI, 0.731-0.970; P < 0.001). The sensitivity was 73.7%, and the specificity was 80%. CONCLUSION END in minor stroke with LVO was distinguishable from those without END following the determination of pNFL in the blood samples within 24 h of onset. The pNFL is a promising biomarker of END in minor stroke with LVO. CLINICAL TRIAL REGISTRATION ChiCTR1800020330.
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Affiliation(s)
- Zhiqiang Wang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China,Department of Neurology, Chengdu BOE Hospital, Chengdu, China
| | - Shuai Wang
- Department of Outpatient, The General Hospital of Western Theater Command, Chengdu, China
| | - Yuxia Li
- Department of Neurology, Chengdu BOE Hospital, Chengdu, China
| | - Rongyu Wang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lianyan Jiang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bo Zheng
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Yaodan Zhang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qingsong Wang
- Department of Neurology, The General Hospital of Western Theater Command, Chengdu, China
| | - Jian Wang
- Department of Neurology, Ya'an People's Hospital, Ya'an, China,*Correspondence: Jian Wang
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7
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Kim BJ, Menon BK, Yoo J, Han JH, Kim BJ, Kim CK, Kim JG, Kim JT, Park H, Baik SH, Han MK, Kang J, Kim JY, Lee KJ, Park JM, Kang K, Lee SJ, Cha JK, Kim DH, Jeong JH, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi KH, Choi JC, Kim JG, Kwon JH, Kim WJ, Shin DI, Yum KS, Sohn SI, Hong JH, Kim C, Lee SH, Lee J, Almekhlafi MA, Demchuk A, Bae HJ. Effectiveness and safety of EVT in patients with acute LVO and low NIHSS. Front Neurol 2022; 13:955725. [PMID: 35989920 PMCID: PMC9389111 DOI: 10.3389/fneur.2022.955725] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purposeThere is much uncertainty in endovascular treatment (EVT) decisions in patients with acute large vessel occlusion (LVO) and mild neurological deficits.MethodsFrom a prospective, nationwide stroke registry, all patients with LVO and baseline NIHSS <6 presenting within 24 h from the time last known well (LKW) were included. Early neurological deterioration (END) developed before EVT was prospectively collected as an increasing total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores during hospitalization not related to EVT. Significant hemorrhage was defined as PH2 hemorrhagic transformation or hemorrhage at a remote site. The modified Rankin Scale (mRS) was prospectively collected at 3 months.ResultsAmong 1,083 patients, 149 (14%) patients received EVT after a median of 5.9 [3.6–12.3] h after LKW. In propensity score-matched analyses, EVT was not associated with mRS 0-1 (matched OR 0.99 [0.63–1.54]) but increased the risk of a significant hemorrhage (matched OR, 4.51 [1.59–12.80]). Extraneous END occurred in 207 (19%) patients after a median of 24.5 h [IQR, 13.5–41.9 h] after LKW (incidence rate, 1.41 [95% CI, 1.23–1.62] per 100 person-hours). END unrelated to EVT showed a tendency to modify the effectiveness of EVT (P-for-interaction, 0.08), which decreased the odds of having mRS 0–1 in mild LVO patients without END (adjusted OR, 0.63 [0.40–0.99]).ConclusionsThe use of EVT in patients with acute LVO and low NIHSS scores may require the assessment of individual risks of early deterioration, hemorrhagic complications and expected benefit.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- *Correspondence: Beom Joon Kim
| | - Bijoy K. Menon
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yongin-si, South Korea
| | - Jung Hoon Han
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jihoon Kang
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Keon-Joo Lee
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si, South Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, South Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Jin-Heon Jeong
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, South Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, South Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Joong-Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Chulho Kim
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, South Korea
| | - Sang-Hwa Lee
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, South Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University, Seoul, South Korea
| | - Mohammed A. Almekhlafi
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Andrew Demchuk
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
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Li Y, Cui R, Fan F, Lu Y, Ai Y, Liu H, Liu S, Du Y, Qin Z, Sun W, Yu Q, Liu Q, Cheng Y. The Efficacy and Safety of Ischemic Stroke Therapies: An Umbrella Review. Front Pharmacol 2022; 13:924747. [PMID: 35935837 PMCID: PMC9355553 DOI: 10.3389/fphar.2022.924747] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Ischemic stroke is a leading cause of morbidity and mortality in neurological diseases. Numerous studies have evaluated the efficacy and safety of ischemic stroke therapies, but clinical data were largely inconsistent. Therefore, it is necessary to summarize and analyze the published clinical research data in the field.Objective: We aimed to perform an umbrella review to evaluate the efficacy and safety of ischemic stroke therapies.Methods: We conducted a search for meta-analyses and systematic reviews on PubMed, the Cochrane Library, and the Web of Science to address this issue. We examined neurological function deficit and cognitive function scores, quality of life, and activities of daily living as efficacy endpoints and the incidence of adverse events as safety profiles.Results: Forty-three eligible studies including 377 studies were included in the umbrella review. The results showed that thrombolytic therapy (tPA; alteplase, tenecteplase, and desmoteplase), mechanical thrombectomy (MTE), edaravone with tPA, stem cell-based therapies, stent retrievers, acupuncture with Western medicines, autologous bone marrow stromal cells, antiplatelet agents (aspirin, clopidogrel, and tirofiban), statins, and Western medicines with blood-activating and stasis-dispelling herbs (NaoShuanTong capsule, Ginkgo biloba, Tongqiao Huoxue Decoction, Xuesaitong injection) can improve the neurological deficits and activities of daily living, and the adverse effects were mild for the treatment of ischemic stroke. Moreover, ligustrazine, safflower yellow, statins, albumin, colchicine, MLC601, salvianolic acids, and DL-3-n-butylphthalide showed serious adverse events, intracranial hemorrhage, or mortality in ischemic stroke patients.Conclusion: Our study demonstrated that tPA, edaravone and tPA, tPA and MTE, acupuncture and Western medicines, and blood-activating and stasis-dispelling herbs with Western medicines are the optimum neurological function and activities of daily living medication for patients with ischemic stroke.Systematic Review Registration: https://inplasy.com/, identifier [INPLASY202250145].
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Affiliation(s)
- Yongbiao Li
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Ruyi Cui
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Fangcheng Fan
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Yangyang Lu
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Yangwen Ai
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Hua Liu
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Shaobao Liu
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Yang Du
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Zhiping Qin
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Wenjing Sun
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
| | - Qianqian Yu
- The People’s Hospital of Xin Tai City (Nephropathy Department), Beijing, China
| | - Qingshan Liu
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
- *Correspondence: Qingshan Liu, ; Yong Cheng,
| | - Yong Cheng
- Key Laboratory of Ethnomedicine of Ministry of Education, School of Pharmacy, Center on Translational Neuroscience, Minzu University of China, Beijing, China
- Institute of National Security, Minzu University of China, Beijing, China
- *Correspondence: Qingshan Liu, ; Yong Cheng,
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9
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Hou X, Feng X, Wang H, Li Q. Mechanical Thrombectomy for Mild Acute Ischemic Stroke with Large-Vessel Occlusion: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2022; 51:615-622. [PMID: 35378529 DOI: 10.1159/000523838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/03/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The functional prognosis of mechanical thrombectomy (MT) for mild acute ischemic stroke (AIS) with large-vessel occlusion (LVO) is controversial. To explore a more precise estimation, a meta-analysis was conducted. METHODS The relevant studies were identified by searching PubMed, Embase, Web of Science, and Cochrane Collaboration Database until October 2021. The pooled analysis, subgroup analysis, sensitivity analysis, and publication bias examination were all conducted. The meta-analysis was performed by using Stata 12.0. RESULTS Eleven studies were included with a total of 1,929 subjects, including 794 patients receiving MT and 1,135 patients receiving medical management. The pooled analysis showed that MT might be not associated with functional prognosis among mild AIS with LVO (excellent functional prognosis: risk ratio (RR) = 1.07, 95% confidence interval (CI) = 0.94-1.21, p = 0.294; favorable functional prognosis: RR = 1.01, 95% CI = 0.96-1.06, p = 0.823). The statistical stability and reliability were demonstrated by the sensitivity analysis and publication bias outcomes. CONCLUSION Our meta-analysis suggests that MT may be not associated with functional prognosis of mild AIS with LVO.
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Affiliation(s)
- Xiaowen Hou
- School of Public Health, Shenyang Medical College, Shenyang, China
| | - Xu Feng
- School of Public Health, Shenyang Medical College, Shenyang, China
| | - Huixin Wang
- School of Public Health, Shenyang Medical College, Shenyang, China
| | - Qian Li
- School of Public Health, Shenyang Medical College, Shenyang, China
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10
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Heit JJ, Muthusami P, Chandra RV, Hui F, Negrotto M, Lee S, Wasserman BA, Abruzzo TA. Reperfusion Therapies for Children With Arterial Ischemic Stroke. Top Magn Reson Imaging 2021; 30:231-243. [PMID: 34613946 DOI: 10.1097/rmr.0000000000000273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Modern hyperacute reperfusion therapies including intravenous thrombolysis and mechanical thrombectomy have transformed the management of arterial ischemic stroke (AIS) in adults. Multiple randomized clinical trials have demonstrated that these therapies enable remarkable improvements in clinical outcome for properly selected patients with AIS. Because pediatric patients were excluded from predicate clinical trials, there is a conspicuous lack of data to guide selection of therapies and inform age-adjusted and pathology-oriented treatment modifications for children. Specifically, technical guidance concerning treatment eligibility, drug dosing, and device implementation is lacking. This review aims to outline important features that differentiate pediatric AIS from adult AIS and provide practical strategies that will assist the stroke specialist with therapeutic decision making.
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Affiliation(s)
- Jeremy J Heit
- Department of Radiology, Stanford University Medical Center, Stanford, CA.,Department of Neurosurgery, Stanford University Medical Center, Stanford, CA
| | | | - Ronil V Chandra
- Monash University Medical Center, Monash University, Melbourne, Australia
| | - Ferdinand Hui
- Johns Hopkins University Medical Center, Baltimore, MD
| | | | - Sarah Lee
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford, CA
| | | | - Todd A Abruzzo
- Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ.,University of Arizona School of Medicine, Phoenix, AZ.,Mayo Clinic College of Medicine, Phoenix, AZ
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11
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Wu X, Khunte M, Payabvash S, Zhu C, Brackett A, Matouk CC, Gandhi D, Sanelli P, Malhotra A. Outcomes after Thrombectomy for Minor Stroke: A Meta-Analysis. World Neurosurg 2020; 149:e1140-e1154. [PMID: 33359881 DOI: 10.1016/j.wneu.2020.12.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the outcomes after mechanical thrombectomy (MT) versus medical management in patients with minor stroke symptomatology. METHODS A meta-analysis was performed for studies reporting outcomes after MT, either as stand-alone therapy or with intravenous thrombolysis in patients with minor stroke and large-vessel occlusion. RESULTS Fourteen studies with 2134 patients met the selection criteria and were included. Two studies compared immediate thrombectomy versus best medical management (with rescue thrombectomy) and the odds ratios of excellent outcomes, good outcomes, mortality and incidence of symptomatic intracranial hemorrhage (sICH) after immediate thrombectomy versus best medical management were 1.07 (95% confidence interval [CI] 0.93-1.22%), 1.15 (95% CI 1.05-1.25), 0.65 (95% CI 0.30-1.38), and 2.89 (95% CI 0.82-10.13), respectively. Among the 8 studies that compared MT outcomes versus medical management (without thrombectomy), odds ratios of excellent outcomes, good outcomes, mortality, and incidence of sICH after MT versus medical management were 0.98 (95% CI 0.89-1.07), 0.94 (95% CI 0.89-1.00), 1.61 (95% CI 1.08-2.41), and 2.59 (95% CI 1.35-4.96), respectively. Among all 14 studies, pooled proportions of excellent outcomes, good outcomes, mortality, and sICH after thrombectomy were 58.7%, 76.2%, 6.82%, and 3.23%, respectively. CONCLUSIONS Our study shows significant selection bias and heterogeneity in the literature with differences in baseline characteristics (age, stroke severity, prestroke modified Rankin Scale score, side of infarct, vessel and site of occlusion, use of intravenous thrombolysis, criteria for clinical deterioration, and selection bias for rescue MT and rates of reperfusion), emphasizing the need for a randomized controlled trial.
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Affiliation(s)
- Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sam Payabvash
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chengcheng Zhu
- Department of Radiology and Biomedical Imaging, University of Washington, Seattle, Washington, USA
| | - Alexandria Brackett
- Clinical Information Services, Yale School of Medicine, New Haven, Connecticut, USA
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Dheeraj Gandhi
- Interventional Neuroradiology Nuclear Medicine, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Pina Sanelli
- Department of Radiology, Northwell Health Imaging Clinical Effectiveness and Outcomes Research (iCEOR) Program, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA.
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12
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Saber H, Khatibi K, Szeder V, Tateshima S, Colby GP, Nour M, Jahan R, Duckwiler G, Liebeskind DS, Saver JL. Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States. Stroke 2020; 51:3241-3249. [PMID: 33081604 DOI: 10.1161/strokeaha.120.030898] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. METHODS Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. RESULTS Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], P<0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], P<0.001). CONCLUSIONS In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.
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Affiliation(s)
- Hamidreza Saber
- Division of Interventional Neuroradiology, Department of Radiological Sciences (H.S., K.K., V.S., S.T., G.P.C., M.N., R.J., G.D.), University of California, Los Angeles (UCLA)
| | - Kasra Khatibi
- Division of Interventional Neuroradiology, Department of Radiological Sciences (H.S., K.K., V.S., S.T., G.P.C., M.N., R.J., G.D.), University of California, Los Angeles (UCLA)
| | - Viktor Szeder
- Division of Interventional Neuroradiology, Department of Radiological Sciences (H.S., K.K., V.S., S.T., G.P.C., M.N., R.J., G.D.), University of California, Los Angeles (UCLA)
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Department of Radiological Sciences (H.S., K.K., V.S., S.T., G.P.C., M.N., R.J., G.D.), University of California, Los Angeles (UCLA)
| | - Geoffrey P Colby
- Division of Interventional Neuroradiology, Department of Radiological Sciences (H.S., K.K., V.S., S.T., G.P.C., M.N., R.J., G.D.), University of California, Los Angeles (UCLA).,Department of Neurosurgery (G.P.C.), University of California, Los Angeles (UCLA)
| | - May Nour
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (M.N., D.S.L., J.L.S.), University of California, Los Angeles (UCLA).,Division of Interventional Neuroradiology, Department of Radiological Sciences (H.S., K.K., V.S., S.T., G.P.C., M.N., R.J., G.D.), University of California, Los Angeles (UCLA)
| | - Reza Jahan
- Division of Interventional Neuroradiology, Department of Radiological Sciences (H.S., K.K., V.S., S.T., G.P.C., M.N., R.J., G.D.), University of California, Los Angeles (UCLA)
| | - Gary Duckwiler
- Division of Interventional Neuroradiology, Department of Radiological Sciences (H.S., K.K., V.S., S.T., G.P.C., M.N., R.J., G.D.), University of California, Los Angeles (UCLA)
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (M.N., D.S.L., J.L.S.), University of California, Los Angeles (UCLA)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (M.N., D.S.L., J.L.S.), University of California, Los Angeles (UCLA)
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13
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McCarthy DJ, Tonetti DA, Stone J, Starke RM, Narayanan S, Lang MJ, Jadhav AP, Gross BA. More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores. J Neurointerv Surg 2020; 13:146-151. [PMID: 33028674 DOI: 10.1136/neurintsurg-2020-016583] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.
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Affiliation(s)
- David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Stone
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Department of Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Sandra Narayanan
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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14
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Zhao Y, Song Y, Guo Y, Li Y, Zhang Y, Ma P, Li G, Li F. Endovascular Thrombectomy VS. Medical Treatment for Mild Stroke Patients: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2020; 29:105258. [PMID: 32992178 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/15/2020] [Accepted: 08/16/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE At present, endovascular thrombectomy (EVT) has been gradually became a standard therapy for stroke patients caused by emergent large-vessel occlusion (ELVO). However, the question about whether EVT is superior to medical treatment for mild stroke patients presenting with a low baseline National Institutes of Health Stroke Scale (NIHSS) score remains unclear. The aim of this systematic review and meta-analysis was to compare the safety and efficacy of EVT with medical treatment in mild stroke patients. MATERIAL AND METHODS A systematic review and meta-analysis was conducted through searching the PubMed, Embase and Cochrane Library databases. All statistical analyses were performed by using Review Manager 5.3 software. Primary outcomes of this meta-analysis were as follows: favorable functional outcome at 90 days (defined as a modified Rankin scale (mRS) score of 0-2); excellent functional outcome at 90 days (defined as a mRS score of 0-1); symptomatic intracerebral hemorrhage (sICH); mortality at 90 days. RESULTS A total of 13 eligible studies with 2135 patients were included in this meta-analysis. The pooled results indicated that mild stroke patients underwent EVT had higher risk of sICH than those receiving medical treatment alone (OR = 3.21; 95% CI, 1.98-5.22; P < 0.001). In addition, no significant difference was found between the two groups in mortality at 90 days (OR = 1.80; 95% CI, 0.88-3.65; P=0.11). Meanwhile, no significant difference was found between the two groups in patients achieving favorable functional outcome at 90 days and excellent functional outcome at 90 days (OR = 1.10; 95% CI, 0.74-1.64; P = 0.65) (OR = 1.03; 95% CI, 0.79-1.35; P = 0.80). CONCLUSIONS Our pooled results showed similar clinical outcomes at 90 days of EVT and medical treatment in mild stroke patients with ELVO, although patients underwent EVT had higher rates of sICH. However, due to several limitations of this meta-analysis, randomized controlled trials are needed to further evaluate the potential efficacy of EVT in mild stroke patients.
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Affiliation(s)
- Yongli Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China
| | - Ying Song
- Department of Pathology, Xinxiang Medical University, Xinxiang, Henan 453000, China
| | - Yingchang Guo
- Department of Interventional Radiology, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China
| | - Yanru Li
- Department of Neurosurgery Intensive Care Unit, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, China
| | - Yi Zhang
- Department of Neurology, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China
| | - Pengju Ma
- Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China
| | - Guangpeng Li
- Department of Emergency, The First Affiliated Hospital, Xinxiang Medical University, Weihui 453100, Henan, China
| | - Fenbao Li
- Department of Interventional Radiology, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, Henan, China.
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15
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Zhao Z, Zhang J, Jiang X, Wang L, Yin Z, Hall M, Wang Y, Lai L. Is Endovascular Treatment Still Good for Ischemic Stroke in Real World?: A Meta-Analysis of Randomized Control Trial and Observational Study in the Last Decade. Stroke 2020; 51:3250-3263. [PMID: 32921259 DOI: 10.1161/strokeaha.120.029742] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Although endovascular treatment (EVT) for acute ischemic stroke is classified as I evidence, outcomes after EVT in real-world practice appear to be less superior than those in randomized clinical trials (RCTs). Additionally, the effect of EVT is unclear compared with medical treatment (MT) for patients with mild symptoms defined by National Institutes of Health Stroke Scale score <6 or with severe symptoms defined by Alberta Stroke Program Early CT Score <6. METHODS Literatures were searched in big databases and major meetings from December 6, 2009, to December 6, 2019, including RCTs and observational studies comparing EVT against MT for patients with acute ischemic stroke. Observational studies were precategorized into 3 groups based on imaging data on admission: mild stroke group with National Institutes of Health Stroke Scale score <6, severe stroke group with Alberta Stroke Program Early CT Score <6 or ischemic core ≥50 mL, and normal stroke group for all others. Outcome was measured as modified Rankin Scale score of 0 to 2, mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) at 24 hours. RESULTS Fifteen RCTs (n=3694) and 37 observational studies (n=9090) were included. EVT was associated with higher modified Rankin Scale 0 to 2 rate and lower mortality in RCTs and normal stroke group, whereas EVT was associated with higher sICH rate in normal stroke group, and no difference of sICH rate appeared between EVT and MT in RCTs. In severe stroke group, EVT was associated with higher modified Rankin Scale 0 to 2 rate and lower mortality, whereas no difference of sICH rate was found. In mild stroke group, there was no difference in modified Rankin Scale 0 to 2 rate between EVT and MT, whereas EVT was associated with higher mortality and sICH rate. CONCLUSIONS Evidence from RCTs and observational studies supports the use of EVT as the first-line choice for eligible patients corresponding to the latest guideline. For patients with Alberta Stroke Program Early CT Score <6, EVT showed superiority over MT, also in line with the guidelines. On the contrary to the guideline, our data do not support EVT for patients with National Institutes of Health Stroke Scale score <6.
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Affiliation(s)
- Zixu Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.).,Queen Mary School, Jiangxi Medical College (Z.Z., J.Z.), Nanchang University, Jiangxi, PR China
| | - Jiarui Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.).,Queen Mary School, Jiangxi Medical College (Z.Z., J.Z.), Nanchang University, Jiangxi, PR China
| | - Xin Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.).,The First Clinical Medical School, Jiangxi Medical College (X.J.), Nanchang University, Jiangxi, PR China
| | - Li Wang
- Centre for Evidence-Based Medicine, School of Public Health (L.W.), Nanchang University, Jiangxi, PR China
| | - Zixiao Yin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, PR China (Z.Y.)
| | - Michael Hall
- Institute of Ophthalmology, University College London, United Kingdom (M.H.)
| | - Yang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.)
| | - Lingfeng Lai
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.)
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16
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Chin F, Waqas M, Chou R, Gerace PG, Rai HH, Vakharia K, Dossani RH, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Impact of endovascular reperfusion on low National Institutes of Health Stroke Scale score large-vessel occlusion stroke. J Stroke Cerebrovasc Dis 2020; 29:104836. [PMID: 32414581 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Effectiveness of mechanical thrombectomy for mild-deficit stroke due to large-vessel occlusion is controversial. We present a single-center consecutive case series on thrombectomy for large-vessel occlusion mild stroke. We evaluated various thrombectomy parameters to better understand disagreement in the literature. METHODS Data from a retrospective cohort of large-vessel occlusion mild stroke patients (National Institutes of Health Stroke Scale <6) treated with mechanical thrombectomy over 6 years and 2 months were analyzed. Patients were divided into 2 groups: successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b or 3) and failed reperfusion (modified Thrombolysis in Cerebral Infarction 0,1, or 2a). Ninety-day modified Rankin Scale in-hospital mortality, and symptomatic hemorrhage rates were compared between groups. Multivariate logistic regression was performed to evaluate reperfusion status as a predictor of 90-day favorable (modified Rankin Scale 0-2) and excellent (modified Rankin Scale 0-1) outcomes. RESULTS We identified 61 patients with large-vessel occlusion mild stroke who underwent thrombectomy. Reperfusion was successful in 49 patients and a failure in 12. The successful group exhibited significantly higher rates of favorable outcome (83.7% vs. 25.0%; p < 0.001) and excellent outcome (69.4% vs.16.7%; p = 0.002) at 90 days. In-hospital mortality was significantly higher in the failure group (41.7% vs.10.2%; p = 0.019). Multivariate logistic regression identified successful reperfusion as a significant predictor (p = 0.001) of 90-day favorable outcome. CONCLUSION Reperfusion success was significantly associated with improved functional outcomes in large-vessel occlusion mild stroke mechanical thrombectomy. Future studies should consider reperfusion rates when evaluating the effectiveness of thrombectomy against that of medical management in these patients.
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Affiliation(s)
- Felix Chin
- 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.
| | - Muhammad Waqas
- 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.
| | - Ryan Chou
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo NY USA; Gifted Math Program, University at Buffalo, Buffalo NY USA.
| | - Peter G Gerace
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo NY USA.
| | - Hamid H Rai
- 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, 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.
| | - Rimal H Dossani
- 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.
| | - 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, New York, USA; Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, 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, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo NY USA; Jacobs Institute, Buffalo NY USA; Department of Neurology, 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, Jacobs School of Medicine and Biomedical Sciences, 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.
| | - 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, Jacobs School of Medicine and Biomedical Sciences, 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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