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Peerlings D, Bennink E, Dankbaar JW, Velthuis BK, Emmer BJ, Hoving JW, Majoie CBLM, Marquering HA, van Voorst H, de Jong HWAM. Standardizing the estimation of ischemic regions can harmonize CT perfusion stroke imaging. Eur Radiol 2024; 34:797-807. [PMID: 37572189 PMCID: PMC10853359 DOI: 10.1007/s00330-023-10035-1] [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: 02/17/2023] [Revised: 04/25/2023] [Accepted: 06/16/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES We aimed to evaluate the real-world variation in CT perfusion (CTP) imaging protocols among stroke centers and to explore the potential for standardizing vendor software to harmonize CTP images. METHODS Stroke centers participating in a nationwide multicenter healthcare evaluation were requested to share their CTP scan and processing protocol. The impact of these protocols on CTP imaging was assessed by analyzing data from an anthropomorphic phantom with center-specific vendor software with default settings from one of three vendors (A-C): IntelliSpace Portal, syngoVIA, and Vitrea. Additionally, standardized infarct maps were obtained using a logistic model. RESULTS Eighteen scan protocols were studied, all varying in acquisition settings. Of these protocols, seven, eight, and three were analyzed with center-specific vendor software A, B, and C respectively. The perfusion maps were visually dissimilar between the vendor software but were relatively unaffected by the acquisition settings. The median error [interquartile range] of the infarct core volumes (mL) estimated by the vendor software was - 2.5 [6.5] (A)/ - 18.2 [1.2] (B)/ - 8.0 [1.4] (C) when compared to the ground truth of the phantom (where a positive error indicates overestimation). Taken together, the median error [interquartile range] of the infarct core volumes (mL) was - 8.2 [14.6] before standardization and - 3.1 [2.5] after standardization. CONCLUSIONS CTP imaging protocols varied substantially across different stroke centers, with the perfusion software being the primary source of differences in CTP images. Standardizing the estimation of ischemic regions harmonized these CTP images to a degree. CLINICAL RELEVANCE STATEMENT The center that a stroke patient is admitted to can influence the patient's diagnosis extensively. Standardizing vendor software for CT perfusion imaging can improve the consistency and accuracy of results, enabling a more reliable diagnosis and treatment decision. KEY POINTS • CT perfusion imaging is widely used for stroke evaluation, but variation in the acquisition and processing protocols between centers could cause varying patient diagnoses. • Variation in CT perfusion imaging mainly arises from differences in vendor software rather than acquisition settings, but these differences can be reconciled by standardizing the estimation of ischemic regions. • Standardizing the estimation of ischemic regions can improve CT perfusion imaging for stroke evaluation by facilitating reliable evaluations independent of the admission center.
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Affiliation(s)
- Daan Peerlings
- Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX, The Netherlands.
| | - Edwin Bennink
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, 3584CX, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, 1105AZ, The Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, 1105AZ, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, 1105AZ, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, 1105AZ, The Netherlands
- Department of Biomedical Engineering and Physics, Location Academic Medical Center, Amsterdam University Medical Centers, Amsterdam, 1105AZ, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, 1105AZ, The Netherlands
- Department of Biomedical Engineering and Physics, Location Academic Medical Center, Amsterdam University Medical Centers, Amsterdam, 1105AZ, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX, The Netherlands
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Samuels N, van de Graaf RA, Roos YBWM, Dippel D, van der Lugt A. Advancements in diagnostic and interventional radiology for stroke treatment: the path from trial to bedside through the pre-MR CLEAN, MR CLEAN, and MR CLEAN II eras. Insights Imaging 2024; 15:30. [PMID: 38289430 PMCID: PMC10828318 DOI: 10.1186/s13244-023-01597-1] [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: 08/31/2023] [Accepted: 11/20/2023] [Indexed: 02/02/2024] Open
Abstract
The stroke field is inevitably connected with imaging in which radiologists fulfill a central role. Our landmark MR CLEAN trial led to the implementation of baseline computed tomography angiography or magnetic resonance angiography in the acute stroke workup and subsequent endovascular treatment (EVT) for ischemic stroke patients with a large vessel occlusion in the anterior circulation, resulting in numerous patients worldwide currently being treated often successfully. A reversal of the pathophysiologic process behind an acute cerebrovascular event was made possible. Subsequently, in the MR CLEAN II trials, the clinical impact of both diagnostic and interventional radiologists remained a cornerstone of our research, which means value-based radiology. Within these MR CLEAN II trials, we proved that aspirin and heparin during EVT should be avoided due to increased symptomatic intracranial hemorrhage risk (MR CLEAN-MED). We concluded there is additional benefit of EVT in the 6-to-24-h window after stroke in the presence of good collaterals on baseline CTA (MR CLEAN-LATE). The impactful success of our stroke trials that changed many guidelines was mainly attributable to (1) the societal burden of the disease, with two thirds of patients dying or being independent at 3 months; (2) the fact that stroke is a common disease, (3) the relatively simple and pragmatic approach of the trials resembling real-world setting; (4) the acceleration of implementation in clinical practice facilitated by a structured approach to guideline development and conditional funding; and foremost (5) the excellent collaboration on a professional level between-disciplines, i.e., diagnostic radiologists, interventionalists, and neurologists.Critical relevance statement The MR CLEAN and MR CLEAN II trials have had tremendous impact on clinical practice, directly by more patients being treated with an effective intervention and indirectly through adoption of evidence-based guidelines. It is in this setting of stroke treatment that diagnostic and interventional radiologists have played a crucial role and created clinical impact.
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Affiliation(s)
- Noor Samuels
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Yvo B W M Roos
- Department of Neurology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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Han X, Li Y, Chen X, Pan D, Mo J, Qiu J, Li Y, Chen Y, Huang Y, Shen Q, Tang Y. Platelet-activating factor antagonist-based intensive antiplatelet strategy in acute ischemic stroke: A propensity score matched with network pharmacology analysis. CNS Neurosci Ther 2023; 29:4082-4092. [PMID: 37435773 PMCID: PMC10651968 DOI: 10.1111/cns.14331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/25/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Diterpene ginkgolides meglumine injection (DGMI) is a platelet-activating factor receptor (PAFR) antagonist that can be used to treat acute ischemic stroke (AIS). This study evaluated the efficacy and safety of an intensive antiplatelet strategy based on PAFR antagonists and explored the underlying mechanisms of PAFR antagonists in AIS treatment. METHODS This is a retrospective study applying propensity score methods to match AIS patients treated with DGMI to nontreated patients. The primary outcome was functional independence (modified Rankin Scale [mRS] 0-2) at 90 days. The safety outcome was bleeding risk. We used McNemar test to compare the efficacy outcome. Subsequently, the network pharmacology analysis was performed. RESULTS 161 AIS patients treated with DGMI in the study were matched with 161 untreated patients. Compared with untreated patients, DGMI-treated patients had a significantly higher rate of mRS ranking 0-2 at 90 days (82.0% vs. 75.8%, p < 0.001), without increased risk of bleeding. The gene enrichment analysis showed that the overlap genes of DGMI targeted and AIS-related enriched in thrombosis and inflammatory-related signaling pathways. CONCLUSIONS An intensive antiplatelet strategy of DGMI plus traditional antiplatelet agents is effective in treating AIS and may work by mediating post-stroke inflammation and thrombosis.
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Affiliation(s)
- Xiaoyan Han
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
| | - Youjia Li
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Xuemin Chen
- Guangdong Medical UniversityZhanjiangPeople's Republic of China
| | - Dong Pan
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
| | - Junning Mo
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Jiaming Qiu
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Yi Li
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
| | - Yan Chen
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Yan Huang
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Qingyu Shen
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
| | - Yamei Tang
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
- Guangdong Province Key Laboratory of Brain Function and Disease, Zhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouPeople's Republic of China
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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van der Steen W, van der Ende NAM, Luijten SPR, Rinkel LA, van Kranendonk KR, van Voorst H, Roosendaal SD, Beenen LFM, Coutinho JM, Emmer BJ, van Oostenbrugge RJ, Majoie CBLM, Lingsma HF, van der Lugt A, Dippel DWJ, Roozenbeek B. Type of intracranial hemorrhage after endovascular stroke treatment: association with functional outcome. J Neurointerv Surg 2023; 15:971-976. [PMID: 36261280 PMCID: PMC10511981 DOI: 10.1136/jnis-2022-019474] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/03/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is a frequent complication after endovascular stroke treatment. OBJECTIVE To assess the association of the occurrence and type of ICH after endovascular treatment (EVT) with functional outcome. METHODS We analyzed data from the MR CLEAN-NO IV and MR CLEAN-MED trials. Both trials included adult patients with ischemic stroke with a large vessel occlusion in the anterior circulation, who were eligible for EVT. ICH was classified (1) as asymptomatic or symptomatic (concomitant neurological deterioration of ≥4 points on the NIHSS, or ≥2 points on 1 NIHSS item), and (2) according to the Heidelberg Bleeding Classification. We used multivariable ordinal logistic regression analyses to assess the association of the occurrence and type of ICH with the modified Rankin Scale score at 90 days. RESULTS Of 1017 included patients, 331 (33%) had an asymptomatic ICH, and 90 (9%) had a symptomatic ICH. Compared with no ICH, both asymptomatic (adjusted common OR (acOR)=0.76; 95% CI 0.58 to 0.98) and symptomatic (acOR=0.07; 95% CI 0.04 to 0.14) ICH were associated with worse functional outcome. In particular, isolated parenchymal hematoma type 2 (acOR=0.37; 95% CI 0.14 to 0.95), combined parenchymal hematoma with hemorrhage outside infarcted brain tissue (acOR=0.17; 95% CI 0.10 to 0.30), and combined hemorrhages outside infarcted brain tissue (acOR=0.14; 95% CI 0.03 to 0.74) were associated with worse functional outcome than no ICH.Strength of the association of ICH with functional outcome depends on the type of ICH. Although the association is stronger for symptomatic ICH, asymptomatic ICH after EVT is also associated with worse functional outcome.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nadinda A M van der Ende
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sven P R Luijten
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Katinka R van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Stefan D Roosendaal
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Bob Roozenbeek
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
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6
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Klail T, Sedova P, Vinklarek JF, Kovacova I, Bar M, Cihlar F, Cernik D, Kočí L, Jura R, Herzig R, Husty J, Kocher M, Kovar M, Nevšímalová M, Raupach J, Rocek M, Sanak D, Sevcik P, Skoloudik D, Sramek M, Vanicek J, Vaško P, Vaclavik D, Tomek A, Mikulik R. Safety and Efficacy of Baseline Antiplatelet Treatment in Patients Undergoing Mechanical Thrombectomy for Ischemic Stroke: Antiplatelets Before Mechanical Thrombectomy. J Vasc Interv Radiol 2023; 34:1502-1510.e12. [PMID: 37192724 DOI: 10.1016/j.jvir.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/17/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE To investigate the safety and efficacy of baseline antiplatelet treatment in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). MATERIALS AND METHODS Baseline use of antiplatelet medication before MT for (AIS) may provide benefit on reperfusion and clinical outcome but could also carry an increased risk of intracranial hemorrhage (ICH). All consecutive patients with AIS and treated with MT with and without intravenous thrombolysis (IVT) between January 2012 and December 2019 in all centers performing MT nationwide were reviewed. Data were prospectively collected in national registries (eg, SITS-TBY and RES-Q). Primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months; secondary outcome was ICH. RESULTS Of the 4,351 patients who underwent MT, 1,750 (40%) and 666 (15%) were excluded owing to missing data from the functional independence and ICH outcome cohorts, respectively. In the functional independence cohort (n = 2,601), 771 (30%) patients received antiplatelets before MT. Favorable outcome did not differ in any antiplatelet, aspirin, and clopidogrel groups when compared with that in the no-antiplatelet group: odds ratio (OR), 1.00 (95% CI, 0.84-1.20); OR, 1.05 (95% CI, 0.86-1.27); and OR, 0.88 (95% CI, 0.55-1.41), respectively. In the ICH cohort (n = 3,685), 1095 (30%) patients received antiplatelets before MT. The rates of ICH did not increase in any treatment options (any antiplatelet, aspirin, clopidogrel, and dual antiplatelet groups) when compared with those in the no-antiplatelet group: OR, 1.03 (95% CI, 0.87-1.21); OR, 0.99 (95% CI, 0.83-1.18); OR, 1.10 (95% CI, 0.82-1.47); and OR, 1.43 (95% CI, 0.87-2.33), respectively. CONCLUSIONS Antiplatelet monotherapy before MT did not improve functional independence or increase the risk of ICH.
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Affiliation(s)
- Tomas Klail
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Petra Sedova
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Neurology, Mayo Clinic, Rochester, Minnesota; Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Jan F Vinklarek
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ingrid Kovacova
- International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Hospital, Ostrava, Czech Republic; Faculty of Medicine, Ostrava University, Ostrava, Czech Republic
| | - Filip Cihlar
- Department of Radiology, Masaryk's Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czech Republic
| | - David Cernik
- Department of Radiology, Masaryk's Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czech Republic
| | - Lubomir Kočí
- Neurocentre, Regional Hospital Liberec, Liberec, Czech Republic
| | - Rene Jura
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Centre, Charles University Faculty of Medicine and University Hospital in Hradec Králové, Hradec Králové, Czech Republic
| | - Jakub Husty
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Radiology and Nuclear Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Kocher
- Department of Radiology, Palacky University Medical School and Hospital, Olomouc, Czech Republic
| | - Martin Kovar
- Department of Neurology, Na Homolce Hospital, Prague, Czech Republic
| | - Miroslava Nevšímalová
- Department of Neurology, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Jan Raupach
- Department of Radiology, University Hospital and Faculty of Medicine Hradec Králové, Charles University in Prague, Hradec Králové, Czech Republic
| | - Miloslav Rocek
- Department of Radiology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Palacky Medical School and University Hospital, Comprehensive Stroke Center, Olomouc, Czech Republic
| | - Petr Sevcik
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - David Skoloudik
- Center for Health Research, Medical Faculty, Ostrava University, Ostrava, Czech Republic
| | - Martin Sramek
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic; Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jiri Vanicek
- Department of Medical Imaging, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Peter Vaško
- Department of Neurology, Faculty Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Daniel Vaclavik
- Neurology, Agel Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic; Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Ales Tomek
- Department of Neurology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Robert Mikulik
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Huijberts I, Pinckaers FME, van Zwam WH, Boogaarts HD, van Oostenbrugge RJ, Postma AA. Cerebral arterial air emboli on immediate post-endovascular treatment CT are associated with poor short- and long-term clinical outcomes in acute ischaemic stroke patients. J Neuroradiol 2023; 50:530-536. [PMID: 37331695 DOI: 10.1016/j.neurad.2023.06.001] [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: 03/21/2023] [Revised: 05/30/2023] [Accepted: 06/11/2023] [Indexed: 06/20/2023]
Abstract
PURPOSE To determine the incidence and predictors of cerebral arterial air emboli (CAAE) on immediate post-endovascular treatment (EVT) dual-energy CT (DECT) in acute ischaemic stroke (AIS) patients, and describe their association with clinical outcomes. METHODS EVT records from 2010 to 2019 were screened. Exclusion criteria included intracerebral haemorrhage on post-EVT DECT. In the affected middle cerebral artery (MCA)-territory, circular and linear (length ≥ 1.5*width) CAAE were counted. Clinical data were collected from prospective records. The modified Rankin Scale (mRS) at 90 days was the primary outcome. Multivariable linear, logistic, and ordinal regression were used to analyse the effect of (1) linear CAAE and (2) isolated circular CAAE. RESULTS Out of 651 EVT-records, 402 patients were included. In 65 patients (16%), at least one linear CAAE was found in the affected MCA-territory. 17 patients (4%) showed isolated circular CAAE. Multivariable regression showed an association between both the presence and the number of linear CAAE and the mRS at 90 days (presence: adjusted (a)cOR 3.10, 95%CI 1.75-5.50; number: acOR 1.28, 95%CI 1.13-1.44), NIHSS at 24-48 h (presence: aβ 4.15, 95%CI 1.87-6.43; number: aβ 0.88, 95%CI 0.42-1.34), mortality at 90 days (presence: aOR 3.34, 95%CI 1.51-7.40; number: aOR 1.24, 95%CI 1.08-1.43) and stroke progression (presence: aOR 4.01, 95%CI 1.96-8.18; number: aOR 1.31, 95%CI 1.15-1.50). Isolated circular CAAE were not significantly associated with any outcome measure. CONCLUSION CAAE were found frequently on post-EVT CT imaging. The presence and the number of linear CAAE, but not circular CAAE, are associated with unfavourable short- and long-term clinical outcomes.
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Affiliation(s)
- Ilse Huijberts
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, the Netherlands; Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Florentina M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands
| | | | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, the Netherlands; School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, the Netherlands
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8
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Su J, Wolff L, van Doormaal PJ, Dippel DWJ, van Zwam W, Niessen WJ, van der Lugt A, van Walsum T. Time dependency of automated collateral scores in computed tomography angiography and computed tomography perfusion images in patients with intracranial arterial occlusion. Neuroradiology 2023; 65:313-322. [PMID: 36167825 PMCID: PMC9859867 DOI: 10.1007/s00234-022-03050-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The assessment of collateral status may depend on the timing of image acquisition. The purpose of this study is to investigate whether there are optimal time points in CT Perfusion (CTP) for collateral status assessment, and compare collaterals scores at these time points with collateral scores from multiphase CT angiography (mCTA). METHODS Patients with an acute intracranial occlusion who underwent baseline non-contrast CT, mCTA and CT perfusion were selected. Collateral status was assessed using an automatically computed Collateral Ratio (CR) score in mCTA, and predefined time points in CTP acquisition. CRs extracted from CTP were correlated with CRs from mCTA. In addition, all CRs were related to baseline National Institutes of Health Stroke Scale (NIHSS) and Alberta Stoke Program Early CT Score (ASPECTS) with linear regression analysis to find the optimal CR. RESULTS In total 58 subjects (median age 74 years; interquartile range 61-83 years; 33 male) were included. When comparing the CRs from the CTP vs. mCTA acquisition, the strongest correlations were found between CR from baseline mCTA and the CR at the maximal intensity projection of time-resolved CTP (r = 0.81) and the CR at the peak of arterial enhancement point (r = 0.78). Baseline mCTA-derived CR had the highest correlation with ASPECTS (β = 0.36 (95%CI 0.11, 0.61)) and NIHSS (β = - 0.48 (95%CI - 0.72, - 0.16)). CONCLUSION Collateral status assessment strongly depends on the timing of acquisition. Collateral scores obtained from mCTA imaging is close to the optimal collateral score obtained from CTP imaging.
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Affiliation(s)
- Jiahang Su
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | - Lennard Wolff
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Wim van Zwam
- Department of Radiology, Maastricht UMC +, Maastricht, The Netherlands
| | - Wiro J Niessen
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
- Faculty of Applied Science, Delft University of Technology, Delft, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Theo van Walsum
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
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9
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Widimsky P, Snyder K, Sulzenko J, Hopkins LN, Stetkarova I. Acute ischaemic stroke: recent advances in reperfusion treatment. Eur Heart J 2022; 44:1205-1215. [PMID: 36477996 PMCID: PMC10079392 DOI: 10.1093/eurheartj/ehac684] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
During the last 5–7 years, tremendous progress was achieved in the reperfusion treatment of acute ischaemic stroke during its first few hours from symptom onset. This review summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and (in selected patients) carotid stenting. Novel approaches in prehospital (mobile interventional stroke teams) and early hospital (direct transfer to angiography) management are described, and future perspectives (‘all-in-one’ laboratories with angiography and computed tomography integrated) are discussed. There is reasonable chance for patients with moderate-to-severe acute ischaemic stroke to survive without permanent sequelae when the large-vessel occlusion is removed by means of modern pharmaco-mechanic approach. Catheter thrombectomy is now the golden standard of acute stroke treatment. The role of cardiologists in stroke is expanding from diagnostic help (to reveal the cause of stroke) to acute therapy in those regions where such up-to-date Class I. A treatment is not yet available.
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Affiliation(s)
- Petr Widimsky
- Cardiocenter, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
| | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY , USA
| | - Jakub Sulzenko
- Cardiocenter, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
| | - Leo Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY , USA
| | - Ivana Stetkarova
- Department of Neurology at the Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
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10
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Matsubara H, Enomoto Y, Egashira Y, Uchida K, Yamagami H, Sakai N, Yoshimura S. The safety and efficacy of periprocedural intravenous anticoagulants for acute ischemic stroke patients who underwent endovascular treatment: Sub-analysis of the RESCUE-Japan Registry 2. J Neurol Sci 2022; 442:120390. [PMID: 36037667 DOI: 10.1016/j.jns.2022.120390] [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: 01/11/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/17/2022]
Abstract
The efficacy and safety of periprocedural anticoagulant therapy are still controversial. We investigated the effects of periprocedural anticoagulation on patients who underwent endovascular therapy (EVT) for acute ischemic stroke (AIS). The patients were dichotomized into two groups according to the use of intravenous anticoagulant during or within 24 h after EVT (AC or non-AC group). Primary outcome was defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days. Safety outcomes were defined as any or symptomatic intracerebral hemorrhages (ICH). Among 1278 enrolled patients, 740 patients (57.9%) were in the AC group and the remaining 538 patients (42.1%) were in the non-AC group. The median dose of heparin was 5000 units intraoperatively, and 10,000 units /day postoperatively. In the AC group, hypercholesterolemia, higher pre-stroke modified Rankin Scale score, non-cardiac embolism etiology, higher rate of anticoagulant premedication, non-administration of t-PA (tissue plasminogen activator), later admission, and longer procedure time were observed. The rate of primary outcomes was not significantly different between the AC and non-AC groups (40.1% vs. 43.9%; adjusted odds ratio, 1.29; 95% CI, 0.96-1.73; p = 0.09). The incidence of any (26.2% vs. 25.7%; p = 0.80; adjusted odds ratio, 0.97; 95% CI, 0.72-1.22) and symptomatic (4.3% vs. 5.0%; p = 0.52; adjusted OR, 0.83; 95% CI, 0.46-1.51) intracranial hemorrhage within 72 h were not significantly different between the groups. Periprocedural anticoagulant therapy after acute revascularization did not relate to prognosis and intracranial hemorrhage after EVT.
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Affiliation(s)
- Hirofumi Matsubara
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan..
| | - Yusuke Egashira
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical College of Medicine, Nishinomiya, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical College of Medicine, Nishinomiya, Japan
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11
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van der Steen W, van der Sluijs PM, van de Graaf RA, Su R, Wolff L, van Voorst H, den Hertog HM, van Doormaal PJ, van Es ACGM, Staals J, van Zwam W, Lingsma HF, van den Berg R, Majoie CBLM, van der Lugt A, Dippel DWJ, Roozenbeek B. Safety and efficacy of periprocedural antithrombotics in patients with successful reperfusion after endovascular stroke treatment. J Stroke Cerebrovasc Dis 2022; 31:106726. [PMID: 36029687 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106726] [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: 07/08/2022] [Revised: 08/08/2022] [Accepted: 08/15/2022] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVES We aimed to evaluate whether the overall harmful effect of periprocedural treatment with aspirin or heparin during endovascular stroke treatment is different in patients with a successful reperfusion after the procedure. MATERIALS AND METHODS We performed a post-hoc analysis of the MR CLEAN-MED trial, including adult patients with a large vessel occlusion in the anterior circulation eligible for endovascular treatment (EVT). In this trial, patients were randomized for periprocedural intravenous treatment with aspirin or no aspirin (1:1 ratio), and for moderate-dose unfractionated heparin, low-dose unfractionated heparin or no unfractionated heparin (1:1:1 ratio). We tested for interaction between the post-EVT extended thrombolysis in cerebral infarction (eTICI) score and treatment with periprocedural medication with multivariable regression analyses. The primary outcome was the modified Rankin Scale score at 90 days. Secondary outcomes were final infarct volume, intracranial hemorrhage, and symptomatic intracranial hemorrhage. RESULTS Of 534 included patients, 93 (17%) had a post-EVT eTICI score of 0-2a, 115 (22%) a score of 2b, 73 (14%) a score of 2c, and 253 (47%) a score of 3. For both aspirin and heparin, we found no interaction between post-EVT eTICI score and treatment on the modified Rankin Scale score (p=0.76 and p=0.47, respectively). We found an interaction between post-EVT eTICI score and treatment with heparin on the final infarct volume (p=0.01). Of note, this interaction showed a biologically implausible distribution over the subgroups. CONCLUSIONS The overall harmful effect of periprocedural aspirin and unfractionated heparin is not different in patients with a successful reperfusion after EVT.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
| | - P Matthijs van der Sluijs
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ruisheng Su
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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12
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Guo W, Xu J, Ma L, Ma J, Li S, Ren C, Wu L, Wu C, Li C, Chen J, Duan J, Ma Q, Song H, Zhao W, Ji X. Safety and efficacy of different tirofiban administration routes on acute ischemic stroke patients with successful recanalization: A propensity score matching analysis. CNS Neurosci Ther 2022; 28:1993-2000. [PMID: 35962605 PMCID: PMC9627363 DOI: 10.1111/cns.13936] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/12/2022] [Accepted: 07/27/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE This study aimed to explore the effect of different administration routes of a low dose of tirofiban on acute ischemic stroke (AIS) patients with successful recanalization after endovascular treatment (EVT). METHODS This is a cohort study that retrospectively analyzed data of patients with AIS who underwent EVT and achieved successful recanalization from a prospective registry. Eligible patients were divided into three groups according to their use of tirofiban. Propensity score matching (PSM) was used to balance baseline bias. Safety outcomes included any intracranial hemorrhage (ICH) and symptomatic ICH (sICH). Efficacy outcomes included arterial reocclusion, in-hospital mortality, 3-month mortality, and 3-month functional outcomes. RESULTS We included 821 patients with 306 in the no tirofiban group, 202 in the IA + IV tirofiban group, and 313 in the IV tirofiban group. After PSM, each group included 101 patients with balanced baseline characteristics. There was no difference between the IV tirofiban group and the no tirofiban group in terms of safety and efficacy outcomes (all p > 0.05). Compared with no tirofiban, IA + IV tirofiban group did not increase ICH (30.7% vs. 37.6%, p > 0.05) and sICH (6.9% vs. 17.8%, p > 0.05) whereas reduced 3-month mortality (14.3% vs. 28.7%, p < 0.05) and improved 3-month modified Rankin Scale (median 3 vs. 4, p < 0.05). CONCLUSIONS A low dose of tirofiban, regardless of their administration routes, was safe for AIS patients who achieved successful recanalization with EVT, whereas only IA + IV tirofiban improved clinical outcomes.
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Affiliation(s)
- Wenting Guo
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Jiali Xu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Linqing Ma
- Department of NeurologyThe People's Hospital of Suzhou New DistrictSuzhouChina
| | - Jin Ma
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina,Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Longfei Wu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chuanjie Wu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chuanhui Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Jian Chen
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Jiangang Duan
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Qingfeng Ma
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Haiqing Song
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Wenbo Zhao
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina,Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina,Beijing Institute of Brain DisordersCapital Medical UniversityBeijingChina
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13
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Koopman MS, Hoving JW, van Voorst H, Daems JD, Peerlings D, Buskens E, Lingsma HF, Marquering HA, de Jong HWAM, Berkhemer OA, van Zwam WH, van Walderveen MAA, van den Wijngaard I, van der Lugt A, Dippel DWJ, Yoo AJ, Campbell BCV, Kunz WG, Majoie CBLM, Emmer BJ. Cost-effectiveness of CT perfusion for patients with acute ischemic stroke (CLEOPATRA)-Study protocol for a healthcare evaluation study. Eur Stroke J 2022; 7:188-197. [PMID: 35647320 PMCID: PMC9134782 DOI: 10.1177/23969873221092535] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/17/2022] [Indexed: 08/14/2023] Open
Abstract
INTRODUCTION Computed tomography perfusion (CTP) is variably considered to assess eligibility for endovascular thrombectomy (EVT) in acute ischemic (AIS) stroke patients. Although CTP is recommended for patient selection in later (6-24 h) time window, it is currently not recommended in the earlier (0-6 h) time window and the costs and health effects of including CTP for EVT selection remain unknown. We aim to estimate the costs and health effects of using CTP for EVT selection in AIS patients compared to conventional selection. PATIENTS AND METHODS CLEOPATRA is a healthcare evaluation study using clinical and imaging data from multiple, prospective EVT trials and registries in both the earlier and later time windows. To study the long-term health and cost effects, we will construct a ("Markov") health state transition model simulating the clinical outcome over a 5-year follow-up period for CTP-based and conventional selection for EVT. Clinical data acquired within the current study and estimates from the literature will be used as input for probabilities of events, costs, and Quality-Adjusted Life Years (QALYs) per modified Rankin Scale (mRS) subscore. Primary outcome for the cost-effectiveness analysis will be the Incremental Cost-Effectiveness Ratio (ICER) in terms of costs per QALY gained over the simulated follow-up period. STUDY OUTCOMES Outcome measures will be reported as cumulative values over a 5-year follow-up period. DISCUSSION This study will provide preliminary insight into costs and health effects of including CTP in the selection for EVT for AIS patients, presenting between 0 and 24 h after time last known well. The results may be used to develop recommendations and inform further implementation projects and studies.
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Affiliation(s)
- Miou S Koopman
- Department of Radiology and Nuclear
Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear
Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear
Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering
and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The
Netherlands
| | - Jasper D Daems
- Department of Public Health, Erasmus
University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Erasmus
University Medical Center, Rotterdam, the Netherlands
| | - Daan Peerlings
- Department of Biomedical Engineering
and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The
Netherlands
- Department of Radiology, University
Medical Center Utrecht, Utrecht, The Netherlands
| | - Erik Buskens
- Department of Epidemiology, University
Medical Center Groningen, Groningen, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus
University Medical Center, Rotterdam, the Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear
Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering
and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The
Netherlands
| | - Hugo WAM de Jong
- Department of Radiology, University
Medical Center Utrecht, Utrecht, The Netherlands
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear
Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology, University
Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology and Nuclear
Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular
Research Institute Maastricht (CARIM), Maastricht University Medical Center+,
Maastricht, the Netherlands
| | | | | | - Aad van der Lugt
- Department of Radiology and Nuclear
Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus
University Medical Center, Rotterdam, the Netherlands
| | - Albert J Yoo
- Department of Radiology, Texas Stroke
Institute, Dallas-Fort Worth, TX, USA
| | - Bruce CV Campbell
- Department of Medicine and Neurology,
Melbourne Brain Center, Royal Melbourne Hospital, University of Melbourne,
Parkville, VIC, Australia
| | - Wolfgang G Kunz
- Department of Radiology, University
Hospital, LMU Munich, Munich, Germany
| | - Charles BLM Majoie
- Department of Radiology and Nuclear
Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear
Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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14
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van den Bos N, van den Berg SA, Caupain CM, Pols JA, van Middelaar T, Chalos V, Dippel DW, Roos YB, Kappelhof M, Nederkoorn PJ. Patient and proxies' attitudes towards deferred consent in randomised trials of acute treatment for stroke: A qualitative survey. Eur Stroke J 2022; 6:395-402. [PMID: 35342818 PMCID: PMC8948520 DOI: 10.1177/23969873211057421] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/10/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Deferral of consent for participation in a clinical study is a relatively novel procedure, in which informed consent is obtained after randomisation and study treatment. Deferred consent can be used in emergency situations, where small therapeutic time windows limit possibilities for patients to provide informed consent. We aimed to investigate patients' or their proxies' experiences and opinions regarding deferred consent in acute stroke randomised trials. Patients and methods For this qualitative study, Dutch Collaboration for New Treatments of Acute Stroke (CONTRAST) trial participants were selected. Study participants were either patients or their proxies who provided consent and were selected with theoretical sampling based on patient characteristics. Semi-structured interviews were conducted face-to-face or by telephone. Themes and subthemes were iteratively defined. Results Twenty of the 23 interviewed participants (16 patients and 7 proxies) considered deferred consent acceptable. The received study treatment and consent conversation were remembered by 18 participations, although the concept of randomisation and treatment comparison were generally not well understood. Sixteen participants felt capable of overseeing the decision to give deferred consent. Distress in the first days after stroke, lack of understanding and neurological deficits were reasons for feeling incapable of providing consent. Four participants would have preferred a different timing of the consent conversation, of whom two prior to treatment. Conclusion Our study found that deferred consent was considered acceptable by most study participants who provided consent for acute stroke randomised trials. Though they felt capable, the recall and comprehension of consent were overall limited.
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Affiliation(s)
- Noa van den Bos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sophie A van den Berg
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Catalina Mm Caupain
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeannette Aj Pols
- Department of Ethics, Law and Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anthropology, University of Amsterdam, The Netherlands
| | - Tessa van Middelaar
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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15
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van der Steen W, van de Graaf RA, Chalos V, Lingsma HF, van Doormaal PJ, Coutinho JM, Emmer BJ, de Ridder I, van Zwam W, van der Worp HB, van der Schaaf I, Gons RAR, Yo LSF, Boiten J, van den Wijngaard I, Hofmeijer J, Martens J, Schonewille W, Vos JA, Tuladhar AM, de Laat KF, van Hasselt B, Remmers M, Vos D, Rozeman A, Elgersma O, Uyttenboogaart M, Bokkers RPH, van Tuijl J, Boukrab I, van den Berg R, Beenen LFM, Roosendaal SD, Postma AA, Krietemeijer M, Lycklama G, Meijer FJA, Hammer S, van der Hoorn A, Yoo AJ, Gerrits D, Truijman MTB, Zinkstok S, Koudstaal PJ, Manschot S, Kerkhoff H, Nieboer D, Berkhemer O, Wolff L, van der Sluijs PM, van Voorst H, Tolhuisen M, Roos YBWEM, Majoie CBLM, Staals J, van Oostenbrugge RJ, Jenniskens SFM, van Dijk LC, den Hertog HM, van Es ACGM, van der Lugt A, Dippel DWJ, Roozenbeek B. Safety and efficacy of aspirin, unfractionated heparin, both, or neither during endovascular stroke treatment (MR CLEAN-MED): an open-label, multicentre, randomised controlled trial. Lancet 2022; 399:1059-1069. [PMID: 35240044 DOI: 10.1016/s0140-6736(22)00014-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/27/2021] [Accepted: 01/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Aspirin and unfractionated heparin are often used during endovascular stroke treatment to improve reperfusion and outcomes. However, the effects and risks of anti-thrombotics for this indication are unknown. We therefore aimed to assess the safety and efficacy of intravenous aspirin, unfractionated heparin, both, or neither started during endovascular treatment in patients with ischaemic stroke. METHODS We did an open-label, multicentre, randomised controlled trial with a 2 × 3 factorial design in 15 centres in the Netherlands. We enrolled adult patients (ie, ≥18 years) with ischaemic stroke due to an intracranial large-vessel occlusion in the anterior circulation in whom endovascular treatment could be initiated within 6 h of symptom onset. Eligible patients had a score of 2 or more on the National Institutes of Health Stroke Scale, and a CT or MRI ruling out intracranial haemorrhage. Randomisation was done using a web-based procedure with permuted blocks and stratified by centre. Patients were randomly assigned (1:1) to receive either periprocedural intravenous aspirin (300 mg bolus) or no aspirin, and randomly assigned (1:1:1) to receive moderate-dose unfractionated heparin (5000 IU bolus followed by 1250 IU/h for 6 h), low-dose unfractionated heparin (5000 IU bolus followed by 500 IU/h for 6 h), or no unfractionated heparin. The primary outcome was the score on the modified Rankin Scale at 90 days. Symptomatic intracranial haemorrhage was the main safety outcome. Analyses were based on intention to treat, and treatment effects were expressed as odds ratios (ORs) or common ORs, with adjustment for baseline prognostic factors. This trial is registered with the International Standard Randomised Controlled Trial Number, ISRCTN76741621. FINDINGS Between Jan 22, 2018, and Jan 27, 2021, we randomly assigned 663 patients; of whom, 628 (95%) provided deferred consent or died before consent could be asked and were included in the modified intention-to-treat population. On Feb 4, 2021, after unblinding and analysis of the data, the trial steering committee permanently stopped patient recruitment and the trial was stopped for safety concerns. The risk of symptomatic intracranial haemorrhage was higher in patients allocated to receive aspirin than in those not receiving aspirin (43 [14%] of 310 vs 23 [7%] of 318; adjusted OR 1·95 [95% CI 1·13-3·35]) as well as in patients allocated to receive unfractionated heparin than in those not receiving unfractionated heparin (44 [13%] of 332 vs 22 [7%] of 296; 1·98 [1·14-3·46]). Both aspirin (adjusted common OR 0·91 [95% CI 0·69-1·21]) and unfractionated heparin (0·81 [0·61-1·08]) led to a non-significant shift towards worse modified Rankin Scale scores. INTERPRETATION Periprocedural intravenous aspirin and unfractionated heparin during endovascular stroke treatment are both associated with an increased risk of symptomatic intracranial haemorrhage without evidence for a beneficial effect on functional outcome. FUNDING The Collaboration for New Treatments of Acute Stroke consortium, the Brain Foundation Netherlands, the Ministry of Economic Affairs, Stryker, Medtronic, Cerenovus, and the Dutch Heart Foundation.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Bart J Emmer
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Inger de Ridder
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Irene van der Schaaf
- Department of Radiology, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rob A R Gons
- Department of Neurology, Catharina Hospital, Eindhoven, Netherlands
| | - Lonneke S F Yo
- Department of Radiology, Catharina Hospital, Eindhoven, Netherlands
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Ido van den Wijngaard
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands; Department of Radiology, Haaglanden Medical Centre, The Hague, Netherlands
| | | | - Jasper Martens
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, Netherlands
| | | | - Jan Albert Vos
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Anil Man Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Michel Remmers
- Department of Neurology, Amphia Hospital, Breda, Netherlands
| | - Douwe Vos
- Department of Radiology, Amphia Hospital, Breda, Netherlands
| | - Anouk Rozeman
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Otto Elgersma
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, Netherlands; Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Julia van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Issam Boukrab
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - René van den Berg
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Ludo F M Beenen
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Stefan D Roosendaal
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Alida Annechien Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | | | - Geert Lycklama
- Department of Radiology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Frederick J A Meijer
- Department of Medical Imaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Anouk van der Hoorn
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | | | - Martine T B Truijman
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | - Peter J Koudstaal
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sanne Manschot
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Olvert Berkhemer
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - P Matthijs van der Sluijs
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Henk van Voorst
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Manon Tolhuisen
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Sjoerd F M Jenniskens
- Department of Medical Imaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | | | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
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16
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Ma G, Sun X, Cheng H, Burgin WS, Luo W, Jia W, Liu Y, He W, Geng X, Zhu L, Chen X, Shi H, Xu H, Zhang L, Wang A, Mo D, Ma N, Gao F, Song L, Huo X, Deng Y, Liu L, Luo G, Jia B, Tong X, Liu L, Ren Z, Miao Z. Combined Approach to Eptifibatide and Thrombectomy in Acute Ischemic Stroke Because of Large Vessel Occlusion: A Matched-Control Analysis. Stroke 2022; 53:1580-1588. [PMID: 35105182 DOI: 10.1161/strokeaha.121.036754] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients undergoing mechanical thrombectomy (MT), adjunctive antithrombotic might improve angiographic reperfusion, reduce the risk of distal emboli and reocclusion but possibly expose patients to a higher intracranial hemorrhage risk. This study evaluated the safety and efficacy of combined MT plus eptifibatide for acute ischemic stroke. METHODS This was a propensity-matched analysis of data from 2 prospective trials in Chinese populations: the ANGEL-ACT trial (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) in 111 hospitals between November 2017 and March 2019, and the EPOCH trial (Eptifibatide in Endovascular Treatment of Acute Ischemic Stroke) in 15 hospitals between April 2019 and March 2020. The primary efficacy outcome was good outcome (modified Rankin Scale score 0-2) at 3 months. Secondary efficacy outcomes included the distribution of 3-month modified Rankin Scale scores and poor outcome (modified Rankin Scale score 5-6) and successful recanalization. The safety outcomes included any intracranial hemorrhage, symptomatic intracranial hemorrhage, and 3-month mortality. Mixed-effects logistic regression models were used to account for within-hospital clustering in adjusted analyses. RESULTS Eighty-one combination arm EPOCH subjects were matched with 81 ANGEL-ACT noneptifibatide patients. Compared with the no eptifibatide group, the eptifibatide group had significantly higher rates of successful recanalization (91.3% versus 81.5%; P=0.043) and 3-month good outcomes (53.1% versus 33.3%; P=0.016). No significant difference was found in the remaining outcome measures between the 2 groups. All outcome measures of propensity score matching were consistent with mixed-effects logistic regression models in the total population. CONCLUSIONS This matched-control study demonstrated that MT combined with eptifibatide did not raise major safety concerns and showed a trend of better efficacy outcomes compared with MT alone. Overall, eptifibatide shows potential as a periprocedural adjunctive antithrombotic therapy when combined with MT. Further randomized controlled trials of MT plus eptifibatide should be prioritized. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03844594 (EPOCH), NCT03370939 (ANGEL-ACT).
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Affiliation(s)
- Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Huiran Cheng
- Department of Neurosurgery, Anyang People's Hospital, China (H.C., L.Z.)
| | - W Scott Burgin
- Department of Neurology, Morsani College of Medicine University of South Florida, Tampa (W.S.B.)
| | - Weiliang Luo
- Department of Neurology, Huizhou Municipal Central Hospital, China (W.L.)
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Teaching Hospital, Capital Medical University, China (W.J.)
| | - Yajie Liu
- Department of Neurology, Shenzhen Hospital, Southern Medical University, China (Y.L.)
| | - Wenlong He
- Department of Neurology, Xinxiang Central Hospital, China (W.H.)
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, China (X.G.)
| | - Liangfu Zhu
- Department of Neurosurgery, Anyang People's Hospital, China (H.C., L.Z.).,Department of Cerebral Vascular Diseases, Interventional Center, Henan Provincial People's Hospital, Zhengzhou, China (L.Z.)
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital Xiamen University, China (X.C.)
| | - Huaizhang Shi
- Department of Neurosurgery, the First Affiliated Hospital of Harbin Medical University, China (H.S.)
| | - Haowen Xu
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, China (H.X,)
| | | | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University (A.W.)
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.).,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (L.L.)
| | - Gang Luo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
| | | | | | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa (Z.R.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China (G.M., X.S., D.M., N.M., F.G., L.S., X.H., Y.D., L.L., G.L., B.J., X.Y., Z.M.)
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17
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Sarkulova Z, Tokshilykova A, Khamidulla A, Utepkaliyeva A, Ayaganov D, Sarkulov M, Tamosuitis T. Establishing prognostic significance of hypoxia predictors in patients with acute cerebral pathology. Neurol Res 2021; 44:362-370. [PMID: 34758699 DOI: 10.1080/01616412.2021.1996981] [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: 10/19/2022]
Abstract
OBJECTIVES This research aims to study the prognostic role of serum S100 as a predictor of mortality in vascular and traumatic brain injuries. METHODS This prospective cohort study involved 219 patients. In the blood serum, neuron-specific markers (S100, NSE) and glucose, acid-base state and gas composition of arterial blood were obtained at admission, on the 3rd, 5th and 7th days of patients' stay in the intensive care unit. RESULTS The most significant risk factor for an unfavorable outcome is the marker S100 with a cut-off point of 0.2 mcg/l. The analysis results indicate a statistically significant direct relationship between S100 > 0.2 mcg/l and NSE ≥ 18.9 ng/ml compared to other variables, while the chance ratio (OR) is 11.9 (95%CI:3.2927-1.6693;). With blood sugar increase above 7.4 mmol/l, the OR is 3.82 (95% CI: 2.1289-0.5539;); with a Glasgow scale below 13 points, the OR is 3.69 (95% CI: 2.1316-0.4819;); with an increase in pCO2 < 43.5 mm Hg, the OR was 3.15 (95% CI: 1.8916- 0.4062;). The obtained model certainty measure according to pseudo R2 Nagelkerke criterion is 263.5, showing the excellent quality of the mathematical model's predictive ability. The developed prognostic model, including the dependent variable S100 and independent variables as predictors of a poor outcome of NSE, pCO2, GCS and Hb, reached a cut-off point of 84.51%, AUC - 0.88 with high levels of sensitivity and specificity: 91.89% and 64.14%, respectively. NOVELTY This model can be used to predict the outcome in patients with acute cerebral pathology.
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Affiliation(s)
- Zhanslu Sarkulova
- Department of Anesthesiology and Resuscitation, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Ainur Tokshilykova
- Department of Anesthesiology and Resuscitation, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Alima Khamidulla
- Neurology Department, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Aigul Utepkaliyeva
- Neurology Department, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Dinmukhamed Ayaganov
- Department of Neurology, a Course in Psychiatry and Narcology Department, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Marat Sarkulov
- Urology Department, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Tomas Tamosuitis
- Neurosurgery Intensive Care Unit Neurosurgery Department, Organ Procurement Program of the Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
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18
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Pearce S, Maingard JT, Kuan Kok H, Barras CD, Russell JH, Hirsch JA, Chandra RV, Jhamb A, Thijs V, Brooks M, Asadi H. Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications. Clin Neuroradiol 2021; 31:545-558. [PMID: 33646319 DOI: 10.1007/s00062-021-00997-4] [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: 12/02/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
Endovascular techniques have expanded to include balloon and stent-assistance, flow diversion and individualized endovascular occlusion devices, to widen the treatment spectrum for more complex aneurysm morphologies. While usually well-tolerated by patients, endovascular treatment of intracranial aneurysms carries the risk of complications, with procedure-related ischemic complications being the most common. Several antiplatelet agents have been studied in a neurointerventional setting for both prophylaxis and in the setting of intraprocedural thrombotic complications. Knowledge of these antiplatelet agents, evidence for their use and common dosages is important for the practicing neurointerventionist to ensure the proper application of these agents.Part one of this two-part review focused on basic platelet physiology, pharmacology of common antiplatelet medications and future directions and therapies. Part two focuses on clinical applications and evidence based therapeutic regimens.
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Affiliation(s)
- Samuel Pearce
- Department of Radiology, Western Health, 160 Gordon St, 3011, Footscray, Victoria, Australia. .,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.
| | - Julian T Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hong Kuan Kok
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Interventional Radiology Service, Northern Health Radiology, Melbourne, Victoria, Australia
| | - Christen D Barras
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash University, Melbourne, Victoria, Australia
| | - Ash Jhamb
- Interventional Neuroradiology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
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19
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Vakhitov KM, Cherniakov IS, Khotchenkov MV, Vintskovskiĭ SG, Kmetik ÉG, Vinokurov AI. [Stagewise treatment of tandem lesions of the internal carotid artery in patients with ischaemic stroke]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:50-58. [PMID: 35050249 DOI: 10.33529/angio2021408] [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: 06/14/2023]
Abstract
AIM The study was aimed at assessing the results of a stagewise approach to surgical treatment of patients with ischaemic stroke and tandem lesions of coronary arteries. PATIENTS AND METHODS We analysed the results of treating a total of 19 patients with ischaemic stroke having endured in 2017-2018 surgical interventions for tandem lesions of the internal carotid artery. All 19 patients with tandem lesions underwent as the first stage of surgical treatment recanalization of the intracranial portion of the internal carotid artery. Nine patients were subjected to thromboextraction followed by carotid stenting (Group One), ten underwent thromboextraction and carotid endarterectomy (Group Two). One patient was subjected to simultaneous endovascular intervention at the intra- and extracranial level, in 18 patients reconstruction of the internal carotid artery at the extracranial level (second stage) was performed within a postponed period (3-5 days). In the postoperative period we assessed neurological deficit and the results of 90-day survival. RESULTS No deterioration of neurological deficit was observed after the first stage of surgical treatment. There were statistically significant differences in the degree of regression of a stagewise treatment at discharge, with predominance in the second group. The 90-day survival rate had no prevalence in either group, despite 1 lethal outcome in a patient with simultaneous thromboextraction and stenting of the extracranial portion of the internal carotid artery. CONCLUSION Adequate prevention of haemorrhagic transformation of the damaged zone of cerebral tissue in patients with ischaemic stroke caused by tandem lesions of carotid arteries may be ensured by means of selecting stagewise treatment, i. e., postponed elimination of extracranial stenosis of the internal carotid artery. Given a small sample size, the study requires further examination and assessment of the obtained results.
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Affiliation(s)
- K M Vakhitov
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - I S Cherniakov
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - M V Khotchenkov
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - S G Vintskovskiĭ
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - É G Kmetik
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - A Iu Vinokurov
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
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