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Sun F, Zhou J, Chen X, Yang T, Wang G, Ge J, Zhang Z, Mei Z. No-reflow after recanalization in ischemic stroke: From pathomechanisms to therapeutic strategies. J Cereb Blood Flow Metab 2024; 44:857-880. [PMID: 38420850 DOI: 10.1177/0271678x241237159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Endovascular reperfusion therapy is the primary strategy for acute ischemic stroke. No-reflow is a common phenomenon, which is defined as the failure of microcirculatory reperfusion despite clot removal by thrombolysis or mechanical embolization. It has been reported that up to 25% of ischemic strokes suffer from no-reflow, which strongly contributes to an increased risk of poor clinical outcomes. No-reflow is associated with functional and structural alterations of cerebrovascular microcirculation, and the injury to the microcirculation seriously hinders the neural functional recovery following macrovascular reperfusion. Accumulated evidence indicates that pathology of no-reflow is linked to adhesion, aggregation, and rolling of blood components along the endothelium, capillary stagnation with neutrophils, astrocytes end-feet, and endothelial cell edema, pericyte contraction, and vasoconstriction. Prevention or treatment strategies aim to alleviate or reverse these pathological changes, including targeted therapies such as cilostazol, adhesion molecule blocking antibodies, peroxisome proliferator-activated receptors (PPARs) activator, adenosine, pericyte regulators, as well as adjunctive therapies, such as extracorporeal counterpulsation, ischemic preconditioning, and alternative or complementary therapies. Herein, we provide an overview of pathomechanisms, predictive factors, diagnosis, and intervention strategies for no-reflow, and attempt to convey a new perspective on the clinical management of no-reflow post-ischemic stroke.
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Affiliation(s)
- Feiyue Sun
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Jing Zhou
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Xiangyu Chen
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Tong Yang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Guozuo Wang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Jinwen Ge
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
- Hunan Academy of Chinese Medicine, Changsha, Hunan, China
| | - Zhanwei Zhang
- The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Zhigang Mei
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
- Third-Grade Pharmacological Laboratory on Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, College of Medicine and Health Sciences, China Three Gorges University, Yichang, Hubei, China
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Alexandre AM, Monforte M, Brunetti V, Scarcia L, Cirillo L, Zini A, Scala I, Nardelli V, Arbia F, Arbia G, Frisullo G, Kalsoum E, Camilli A, De Leoni D, Colò F, Abruzzese S, Piano M, Rollo C, Macera A, Ruggiero M, Lafe E, Gabrieli JD, Cester G, Limbucci N, Arba F, Ferretti S, Da Ros V, Bellini L, Salsano G, Mavilio N, Russo R, Bergui M, Caragliano AA, Vinci SL, Romano DG, Frauenfelder G, Semeraro V, Ganimede MP, Lozupone E, Romi A, Cavallini A, Milonia L, Muto M, Candelaresi P, Calabresi P, Pedicelli A, Broccolini A. Baseline clinical and neuroradiological predictors of outcome in patients with large ischemic core undergoing mechanical thrombectomy: A retrospective multicenter study. Int J Stroke 2024:17474930241245828. [PMID: 38546177 DOI: 10.1177/17474930241245828] [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: 04/17/2024]
Abstract
BACKGROUND Recent randomized trials have shown the benefit of mechanical thrombectomy (MT) also in patients with an established large ischemic core. AIMS The purpose of this study was to define baseline predictors of clinical outcome in patients with large vessel occlusion (LVO) in the anterior circulation and an Alberta Stroke Program Early CT score (ASPECTS) ⩽ 5, undergoing MT. MATERIAL AND METHODS The databases of 16 comprehensive stroke centers were retrospectively screened for patients with LVO and ASPECTS ⩽5 that received MT. Baseline clinical and neuroradiological features, including the differential contribution of all ASPECTS regions to the composite score, were collected. Primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2. Statistical analysis used a logistic regression model and random forest algorithm. RESULTS A total of 408 patients were available for analysis. In multivariate model, among baseline features, lower age (odd ratio (OR) = 0.962, 95% confidence interval (CI) = 0.943-0.982) and lower National Institute of Health Stroke Scale (NIHSS) score (OR = 0.911, 95% CI = 0.862-0.963) were associated with the mRS score 0-2. Involvement of the M2 (OR = 0.398, 95% CI = 0.206-0.770) or M4 (OR = 0.496, 95% CI = 0.260-0.945) ASPECTS regions was associated with an unfavorable outcome. Random forest analysis confirmed that age and baseline NIHSS score are the most important variables influencing clinical outcome, whereas involvement of cortical regions M5, M4, M2, and M1 can have a negative impact. CONCLUSION Our retrospective analysis shows that, along with age and baseline clinical impairment, presence of early ischemic changes involving cortical areas has a role in clinical outcome in patients with large ischemic core undergoing MT. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request.
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Affiliation(s)
- Andrea M Alexandre
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Monforte
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Brunetti
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Scarcia
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | - Luigi Cirillo
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Irene Scala
- Catholic University School of Medicine, Rome, Italy
| | - Vincenzo Nardelli
- Department of Statistical Sciences, Catholic University, Rome, Italy
| | - Francesco Arbia
- Department of Neuroradiology, S. Andrea Hospital, Rome, Italy
| | - Giuseppe Arbia
- Department of Statistical Sciences, Catholic University, Rome, Italy
| | - Giovanni Frisullo
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Erwah Kalsoum
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | | | | | | | | | - Mariangela Piano
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Rollo
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Ruggiero
- Neuroradiology Unit, M. Bufalini Hospital, Cesena, Italy
| | - Elvis Lafe
- Neuroradiology Unit, M. Bufalini Hospital, Cesena, Italy
| | | | - Giacomo Cester
- Neuroradiology Unit, Padua University Hospital, Padua, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, A.O.U. Careggi, Florence, Italy
| | | | - Simone Ferretti
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Valerio Da Ros
- Department of Biomedicine and Prevention, "Tor Vergata" University Hospital, Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, "Tor Vergata" University Hospital, Rome, Italy
| | | | - Nicola Mavilio
- Neuroradiology Unit, "San Martino" Hospital, Genoa, Italy
| | - Riccardo Russo
- Neuroradiology Unit, A.O. "Città della Salute e della Scienza," Turin, Italy
| | - Mauro Bergui
- Neuroradiology Unit, A.O. "Città della Salute e della Scienza," Turin, Italy
| | | | - Sergio L Vinci
- Neuroradiology Unit, "G. Martino" Hospital, Messina, Italy
| | - Daniele G Romano
- Neuroradiology Unit, AOU "S Giovanni di Dio e Ruggi di Aragona," Salerno, Italy
| | - Giulia Frauenfelder
- Neuroradiology Unit, AOU "S Giovanni di Dio e Ruggi di Aragona," Salerno, Italy
| | - Vittorio Semeraro
- Interventional Radiology Unit, "SS Annunziata" Hospital, Taranto, Italy
| | | | | | - Andrea Romi
- Neuroradiology Unit, IRCCS "San Matteo" Hospital, Pavia, Italy
| | - Anna Cavallini
- Cerebrovascular Diseases Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | - Luca Milonia
- Interventional Neuroradiology Unit, "Umberto I" University Hospital, Rome, Italy
| | - Massimo Muto
- Neuroradiology Unit, A.O.R.N. "Antonio Cardarelli," Naples, Italy
| | | | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Alessandro Pedicelli
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Aldobrando Broccolini
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
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Xu B, Yin T, Sun T, Li Z, Zhang Z, Lv H, Tian C, Wang J, Hao J, Zhang L. Peripheral blood syndecan-1 levels after mechanical thrombectomy can predict the clinical prognosis of patients with acute ischemic stroke. Acta Neurochir (Wien) 2024; 166:153. [PMID: 38536487 DOI: 10.1007/s00701-024-06004-2] [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: 12/13/2023] [Accepted: 01/28/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Previously, we revealed noticeable dynamic fluctuations in syndecan-1 levels in the peripheral blood of post-stroke patients. We further investigated the clinical prognostic value of syndecan-1 as a biomarker of glycoprotein damage in patients with acute ischaemic stroke (AIS). METHODS We examined 105 patients with acute large vessel occlusion in the anterior circulation, all of whom underwent mechanical thrombectomy (MT). Peripheral blood syndecan-1 levels were measured 1 day after MT, and patients were categorised into favourable and unfavourable prognostic groups based on the 90-day modified Rankin Scale (mRS) score. Additionally, we compared the clinical outcomes between groups with high and low syndecan-1 concentrations. RESULTS The findings revealed a significantly lower syndecan-1 level in the group with an unfavourable prognosis compared to those with a favourable prognosis (p < 0.01). In the multivariable logistic regression analysis, lower syndecan-1 levels were identified as a predictor of unfavourable prognosis (odds ratio (OR) = 0.965, p = 0.001). Patients displaying low syndecan-1 expression in the peripheral blood (< 29.51 ng/mL) experienced a > twofold increase in the rates of unfavourable prognosis and mortality. CONCLUSIONS Our study demonstrates that syndecan-1, as an emerging, easily detectable stroke biomarker, can predict the clinical outcomes of patients with AIS. After MT, low levels of syndecan-1 in the peripheral blood on the first day emerged as an independent risk factor for an unfavourable prognosis, suggesting that lower syndecan-1 levels might signify worse clinical presentation and outcomes in stroke patients undergoing this procedure.
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Affiliation(s)
- Bin Xu
- School of Clinical Medicine, Weifang Medical University, Weifang, China
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Tengkun Yin
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Tanggui Sun
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Zhongchen Li
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Zhiyuan Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Hang Lv
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Chonghui Tian
- Joint Laboratory for Translational Medicine Research, Liaocheng People's Hospital, Liaocheng, 252000, Shandong, China
| | - Jiyue Wang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Jiheng Hao
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China.
| | - Liyong Zhang
- School of Clinical Medicine, Weifang Medical University, Weifang, China.
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China.
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Nguyen TQ, Tran MH, Phung HN, Nguyen KV, Tran HTM, Walter S, Hoang DCB, Pham BN, Truong ALT, Tran VT, Nguyen TN, Pham AL, Nguyen HT. Endovascular treatment for acute ischemic stroke beyond the 24-h time window: Selection by target mismatch profile. Int J Stroke 2024; 19:305-313. [PMID: 37807200 DOI: 10.1177/17474930231208817] [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] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Endovascular treatment for acute ischemic stroke patients with large vessel occlusion (LVO) has been established as a promising clinical intervention within a late time window of 6-24 h after symptom onset. Patients with slow progression, however, may still benefit from endovascular treatment beyond the 24-h time window (very late window). AIM The aim of this study is to report insight into the potential clinical benefits of endovascular treatment for acute ischemic stroke beyond 24 h from symptom onset. METHODS A retrospective analysis was performed on consecutive patients undergoing endovascular treatment for acute anterior circulation LVO ischemic stroke beyond 24 h. Participants were recruited between July 2019 and November 2020. Patients were selected based on the DAWN/DEFUSE 3 criteria (Perfusion-RAPID, iSchemaView) and patients receiving treatment beyond 24 h were compared to a group of patients receiving endovascular treatment between 6 and 24 h after symptom onset. The primary outcome was the proportion of patients with functional independence at 90 days (modified Rankin Scale score of 0-2). The secondary outcomes were shift modified Rankin Scale (mRS) analysis and successful reperfusion was defined by thrombolysis in cerebral infarction (TICI) 2b-3 on the final procedure. Safety outcomes were symptomatic intracranial hemorrhage and death at the 90-day follow-up. Propensity score (PS)-matched analyses were employed to rectify the imbalanced baseline characteristics between the two groups. RESULTS A total of 166 patients were recruited with a median age of 63.0 (56.0-69.0) and 28.9% of all patients were females. Patients in the beyond 24-h group had a longer onset-to-groin time (median = 27.2 vs 14.3 h, p < 0.001) than those in the 6- to 24-h group. There were no statistically significant differences between the two groups in National Institutes of Health Stroke Scale (NIHSS) (median = 12.0 vs 15.0, p = 0.37), perfusion imaging characteristics (core: median = 11.0 vs 9.0 mL, p = 0.86; mismatch volume: median = 106.0 vs 96.0, p = 0.44; mismatch ratio = 6.46 vs 7.24, p = 0.91), and perfusion-to-groin time (median = 72.5 vs 76.0 min, p = 0.77). No significant differences were noted among patients between the two groups in the primary endpoint functional independence analysis (50.0% vs 46.6%, p = 0.77) and in the safety endpoint analysis: mortality (15.0% vs 11.0%, p = 0.71) or symptomatic hemorrhage (0% vs 3.42%, p > 0.999). In PS-matched analyses, there were no significant differences among patients between the two groups in functional independence (50.0% vs 54.8%, p = 0.74), mortality (16.7% vs 9.68%, p = 0.50), or symptomatic hemorrhage (0% vs 6.45%, p = 0.53). CONCLUSION Endovascular treatment can be performed safely and effectively in LVO patients beyond 24 h from symptom onset when selected by target mismatch profile. The clinical outcome of these patients was comparable to those treated in the 6- to 24-h window. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Trung Quoc Nguyen
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Mai Hoang Tran
- School of Public Health, Griffith University, Gold Coast, QLD, Australia
| | - Hai Ngoc Phung
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - Khang Vinh Nguyen
- Department of Neurology, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Hang T Minh Tran
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Silke Walter
- Department of Neurology, Saarland University Hospital, Homburg, Germany
| | - Dinh C Bao Hoang
- Department of Neurology, Tam Anh Hospital, Ho Chi Minh City, Vietnam
| | - Binh Nguyen Pham
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Anh Le Tuan Truong
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Vu Thanh Tran
- Department of Neurointervention, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - An Le Pham
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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Chen G, Wang A, Zhang X, Li Y, Xia X, Tian X, Li J, Miao Z, Yue W. Systemic Immune-Inflammation Response is Associated with Futile Recanalization After Endovascular Treatment. Neurocrit Care 2024:10.1007/s12028-023-01930-y. [PMID: 38316736 DOI: 10.1007/s12028-023-01930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/15/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Frequent incidence of futile recanalization decreases the benefit of endovascular treatment (EVT) in acute ischemic stroke. We hypothesized that the inflammation and immune response after ischemic are associated with futile recanalization. We aimed to investigate the correlation of admission systemic immune-inflammation index (SII) with futile recanalization post EVT. METHODS Patients with successful recanalization (modified Thrombolysis in Cerebral Ischemia angiographic score 2b-3) and maintained artery recanalized after 24 h of EVT were chosen from a prospective nationwide registry study. Futile recanalization was defined as a poor functional outcome (modified Rankin Scale score 3-6) at 90 days, irrespective of a successful recanalization. At admission, SII was calculated as (platelet count × neutrophil count)/lymphocyte count/100. Logistic regression analysis helped to test the relationship of SII with futile recanalization. RESULTS Among the 1,002 patients included, futile recanalization occurred in 508 (50.70%). No matter whether tested as quartiles or continuous variables, SII was significantly associated with futile recanalization (P < 0.05), and for every one standard deviation increase of SII, the risk of futile recanalization elevated by 22.3% (odds ratio 1.223, 95% confidence interval 1.053-1.444, P = 0.0093). Moreover, no significant interactions could be observed between SII or SII quartiles and age, baseline National Institutes of Health Stroke Scale scores, onset-to-recanalization time, and modified Thrombolysis in Cerebral Ischemia angiographic scores (all P for interaction > 0.05). CONCLUSIONS Early SII elevation was associated with an increased risk of futile recanalization among patients with EVT. Our results indicated that therapeutic drug targeting hyperreactive immune-inflammation response might be helpful for reducing the incidence of futile recanalization.
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Affiliation(s)
- Guojuan Chen
- Department of Neurology, Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin Huanhu Hospital, No.6 Jizhao Road, Shuanggang Town, Jinnan District, Tianjin, 300350, China
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaoli Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuhao Li
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Xue Xia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xue Tian
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Jing Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Wei Yue
- Department of Neurology, Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin Huanhu Hospital, No.6 Jizhao Road, Shuanggang Town, Jinnan District, Tianjin, 300350, China.
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Su J, Hu X, Chen L, Li R, Tao C, Yin Y, Liu H, Tan X, Hou S, Xie S, Huo L, Zhu Y, Gong D, Hu W. Predictors of good outcomes and mortality after thrombectomy for basilar artery occlusion within 12 hours of onset. J Neurointerv Surg 2024:jnis-2023-021057. [PMID: 38228387 DOI: 10.1136/jnis-2023-021057] [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: 09/22/2023] [Accepted: 11/12/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Patients with acute basilar artery occlusion (ABAO) who undergo combined standard medical treatment (SMT) and endovascular thrombectomy (EVT) may still have unsatisfactory outcomes. This study was conducted to identify the factors that may impact their outcomes. METHODS We retrospectively reviewed the data of all patients with ABAO combined with SMT and EVT in the endovascular treatment for acute basilar artery occlusion (ATTENTION) trial. A good outcome is defined as a modified Rankin Scale (mRS) score of 0-3, a poor outcome as mRS score of 4-6, and mortality as death at 90-day follow-up. The study analyzed various factors influencing the patients' good outcomes and mortality. RESULTS The study included 221 patients (148 men and 73 women). Among these patients, 45.7% achieved an mRS score of 0-3, while the overall mortality rate was 37.1% (82/221). A good outcome was significantly associated with younger age (adjusted OR 0.96; 95% CI 0.93 to 0.99; P=0.019), a baseline posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) of 8-10 (adjusted OR 2.34; 95% CI 1.07 to 5.12; P=0.034), and post-procedure pc-ASPECTS of 8-10 (adjusted OR 1.40; 95% CI 1.07 to 1.84; P=0.013). Additionally, time from puncture to reperfusion (adjusted OR 2.02; 95% CI 1.2 to 3.41; P=0.008) and intracranial hemorrhage (adjusted OR 3.59; 95% CI 1.09 to 11.8; P=0.035) were associated with 90-day mortality. CONCLUSIONS Younger age, baseline pc-ASPECTS of 8-10, and higher post-procedure pc-ASPECTS could effectively predict good outcomes for patients with ABAO undergoing EVT. Additionally, a prolonged time from puncture to reperfusion and intracranial hemorrhage can independently predict mortality. TRIAL REGISTRATION NUMBER NCT04751708.
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Affiliation(s)
- Junfeng Su
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Xiaohui Hu
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Li Chen
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Rui Li
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
| | - Chunrong Tao
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
| | - Yamei Yin
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
| | - Huanhuan Liu
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Xianhong Tan
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Siyang Hou
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Sanpin Xie
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Longwen Huo
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Yuyou Zhu
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
| | - Daokai Gong
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Wei Hu
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
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Jiang X, Wang J, Hu Y, Lang H, Bao J, Chen N, He L. Is endovascular treatment still good for acute ischemic stroke in the elderly? A meta-analysis of observational studies in the last decade. Front Neurosci 2024; 17:1308216. [PMID: 38249587 PMCID: PMC10796798 DOI: 10.3389/fnins.2023.1308216] [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: 10/06/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Background The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for endovascular treatment (EVT) in elderly patients. This meta-analysis aims to evaluate the therapeutic effects of endovascular treatment for acute ischemic stroke in the elderly compared with younger patients. Methods Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT in elderly patients and those aged <80 years. The primary outcome was functional independence, defined as mRS 0-2 at 90 days after EVT. The secondary outcomes were the rate of successful recanalization, symptomatic intracranial hemorrhage (sICH) and mortality. Odds ratios (ORs) were estimated using a random effects model. Results In total, twenty-six studies with 9,492 enrolled participants were identified. Our results showed that, compared with patients aged <80 years undergoing EVT, EVT was associated with a lower rate of functional independence at 90 days (OR = 0.38; 95% CI, 0.33-0.45; p < 0.00001) and a higher mortality rate (OR = 2.51; 95% CI, 1.98-3.18; p < 0.00001) in the elderly. Furthermore, even without a significantly observed increase in sICH (OR = 1.19; 95% CI, 0.96-1.47; p = 0.11), EVT appeared to be associated with a lower rate of successful recanalization (OR = 0.81; 95% CI, 0.68-0.96; p = 0.02). Conclusion Evidence from observational studies revealed that EVT has less functional outcomes in elderly patients with acute ischemic stroke. Further studies are needed to better identify patients aged ≥80 years who could potentially benefit from EVT.
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Affiliation(s)
| | | | | | | | | | - Ning Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Yang X, Sun D, Huo X, Raynald R, Jia B, Tong X, Wang A, Ma N, Gao F, Mo D, Miao Z. Futile reperfusion of endovascular treatment for acute anterior circulation large vessel occlusion in the ANGEL-ACT registry. J Neurointerv Surg 2023; 15:e363-e368. [PMID: 36693725 DOI: 10.1136/jnis-2022-019874] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Some patients with large vessel occlusion (LVO) still cannot achieve functional independence despite successful reperfusion after endovascular treatment (EVT), named futile reperfusion. We aimed to explore the incidence and predictors of futile reperfusion of EVT for anterior circulation LVO in the Chinese population based on a nationwide prospective multicenter registry. METHODS We selected patients from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) registry. Successful reperfusion was defined as modified Treatment In Cerebral Ischemia (mTICI) 2b-3 after EVT, and functional independence was defined as 90-day modified Rankin Scale (mRS) 0-2. A multivariable regression model was performed to identify the independent predictors of futile reperfusion in anterior circulation LVO patients. RESULTS A total of 1158 anterior circulation LVO patients were included in our study. 600 of the 1158 patients (51.8%) suffered futile reperfusion. Age ≥69 (adjusted OR (aOR) 1.69, 95% CI 1.21 to 2.35, P=0.002), baseline National Institutes of Health Stroke Scale (NIHSS) ≥14 (aOR 2.36, 95% CI 1.71 to 3.27, P<0.001), baseline serum glucose ≥6.5 mmol/L (aOR 1.73, 95% CI 1.27 to 2.36, P=0.001), drip and ship (aOR 1.56, 95% CI 1.11 to 2.18, P=0.011), and general anesthesia (aOR 2.28, 95% CI 1.66 to 3.14, P<0.001) were associated with a high risk of futile reperfusion in the anterior LVO patients after EVT, whereas baseline Alberta Stroke Program Early CT Score (ASPECTS) ≥8 (aOR 0.65, 95% CI 0.47 to 0.91, P=0.011) and complete reperfusion (aOR 0.62, 95% CI 0.43 to 0.89, P=0.010) were associated with a low risk of futile reperfusion in the anterior LVO patients after EVT. CONCLUSIONS In the ANGEL-ACT registry, 51.8% of anterior circulation LVO patients suffered futile reperfusion after EVT. Age ≥69 years, baseline NIHSS ≥14, baseline serum glucose ≥6.5 mmol/L, drip and ship, general anesthesia, baseline ASPECTS <8, and incomplete reperfusion were the independent predictors of futile reperfusion.
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Affiliation(s)
- XinGuang Yang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - BaiXue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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9
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Terceño M, Bashir S, Puig J, I-Estadella JD, Murias E, Jiménez JM, Díaz EG, Monso JF, Bravo-Rey I, Romero V, Werner M, López-Rueda A, Román LS, Anadaluz JB, Doncel-Moriano A, Rosati S, Pérez-García C, Remollo S, Caamaño IR, Aixut S, Chaparro OSC, Garcia JMS, Porto-Álvarez J, Mendez-Cendón JC, Rayon-Aledo JC, Aguilar Y, Parrilla G, Castaño M, Serena J, Silva Y. Impact of Balloon Guide Catheters in Elderly Patients Treated with Mechanical Thrombectomy: Insights from the ROSSETTI Registry. AJNR Am J Neuroradiol 2023; 44:1275-1281. [PMID: 37827717 PMCID: PMC10631533 DOI: 10.3174/ajnr.a8003] [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: 05/05/2023] [Accepted: 08/17/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND PURPOSE Several nonrandomized studies have demonstrated the effectiveness of balloon guide catheters in treating patients with anterior circulation large-vessel occlusion. However, their impact on the elderly populations has been underreported. We aimed to analyze the effect of balloon guide catheters in a cohort of elderly patients (80 years of age or older) with anterior circulation large-vessel occlusion. MATERIALS AND METHODS Consecutive patients from June 2019 to June 2022 were collected from the ROSSETTI Registry. Demographic and clinical data, angiographic endovascular technique, and clinical outcome were compared between balloon guide catheter and non-balloon guide catheter groups. We studied the association between balloon guide catheters and the rate of complete recanalization after a single first-pass effect modified TICI 2c-3, as well as their association with functional independence at 3 months. RESULTS A total of 808 patients were included during this period, 465 (57.5%) of whom were treated with balloon guide catheters. Patients treated with balloon guide catheters were older, had more neurologic severity at admission and lower baseline ASPECTS, and were less likely to receive IV fibrinolytics. No differences were observed in terms of the modified first-pass effect between groups (45.8 versus 39.9%, P = .096). In the multivariable regression analysis, balloon guide catheter use was not independently associated with a modified first-pass effect or the final modified TICI 2c-3, or with functional independence at 3 months. CONCLUSIONS In our study, balloon guide catheter use during endovascular treatment of anterior circulation large-vessel occlusion in elderly patients did not predict the first-pass effect, near-complete final recanalization, or functional independence at 3 months. Further studies, including randomized clinical trials, are needed to confirm these results.
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Affiliation(s)
- Mikel Terceño
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Saima Bashir
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Josep Puig
- Department of Radiology (J.P.), Hospital Universitari de Girona Doctor Josep Trueta, Girona, Catalunya, Spain
| | - Josep Daunis- I-Estadella
- Department of Computer Science (J.D.-I.-E.), Applied Mathematics and Statistics, University of Girona, Girona, Catalunya, Spain
| | - Eduardo Murias
- Department of Radiology (E.M., J.M.J.), Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Jose María Jiménez
- Department of Radiology (E.M., J.M.J.), Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Eva González Díaz
- Department of Interventional Neuroradiology (E.G.D., J.F.M.), Department of Radiology, Cruces University Hospital, Barakaldo, PaísVasco, Spain
| | - Jon Fondevila Monso
- Department of Interventional Neuroradiology (E.G.D., J.F.M.), Department of Radiology, Cruces University Hospital, Barakaldo, PaísVasco, Spain
| | - Isabel Bravo-Rey
- Diagnostic and Therapeutical Neuroradiology Unit (I.B.-R., V.R.), Reina Sofia University Hospital, Cordoba, Andalucía, Spain
| | - Veredas Romero
- Diagnostic and Therapeutical Neuroradiology Unit (I.B.-R., V.R.), Reina Sofia University Hospital, Cordoba, Andalucía, Spain
| | - Mariano Werner
- Neurointerventional Department CDI (M.W.), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Antonio López-Rueda
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | - Luis San Román
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | - Jordi Blasco Anadaluz
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | | | - Santiago Rosati
- Department of Interventional Neurorradiology (S.R., C.P.-G.), Department of Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Carlos Pérez-García
- Department of Interventional Neurorradiology (S.R., C.P.-G.), Department of Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Sebastian Remollo
- Department of Interventional Neuroradiology (S.R., I.R.C.), Hospital universitari Germans Trias i Pujol, Badalona, Spain
| | - Isabel Rodríguez Caamaño
- Department of Interventional Neuroradiology (S.R., I.R.C.), Hospital universitari Germans Trias i Pujol, Badalona, Spain
| | - Sonia Aixut
- Department of Interventional Neuroradiology (S.A., O.S.C.C.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oscar Sabino Chirife Chaparro
- Department of Interventional Neuroradiology (S.A., O.S.C.C.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Jacobo Porto-Álvarez
- Department of Neuroradiology (J.P.-A.), Complexo Hospitalario Universitario de Santiago de, Compostela, Galicia, Spain
| | - Jose Carlos Mendez-Cendón
- Interventional Neuroradiology Unit (J.C.M.-C.), Department of Radiology, Hospital Ramón y Cajal, Madrid, Spain
| | - Jose Carlos Rayon-Aledo
- Department of Interventional Neuroradiology (J.C.R.-A.), Hospital General Universitario de Alicante, Alicante, Valenciana, Spain
| | - Yeray Aguilar
- Department of Radiology (Y.A.), Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Guillermo Parrilla
- Department of Interventional Neuroradiology (G.P.), Department of Radiology, Hospital Clínico Universitario Virgen de la, Murcia, Spain
| | - Miguel Castaño
- Department of Interventional Neuroradiology (M.S.), Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - Joaquín Serena
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Yolanda Silva
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
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10
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van Kranendonk KR, Kappelhof M, Bruggeman AAE, Rinkel LA, Treurniet KM, LeCouffe N, Emmer BJ, Coutinho JM, Wolff L, van Zwam WH, van Oostenbrugge RJ, van der Lugt A, Dippel DWJ, Roos YBWEM, Marquering HA, Majoie CBLM. Hemorrhage rates in patients with acute ischemic stroke treated with intravenous alteplase and thrombectomy versus thrombectomy alone. J Neurointerv Surg 2023; 15:e262-e269. [PMID: 36396434 DOI: 10.1136/jnis-2022-019569] [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: 08/25/2022] [Accepted: 11/01/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intravenous alteplase treatment (IVT) for acute ischemic stroke carries a risk of intracranial hemorrhage (ICH). However, reperfusion of an occluded vessel itself may contribute to the risk of ICH. We determined whether IVT and reperfusion are associated with ICH or its volume in the Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN)-NO IV trial. METHODS The MR CLEAN-NO IV trial randomized patients with acute ischemic stroke due to large vessel occlusion to receive either IVT followed by endovascular treatment (EVT) or EVT alone. ICH was classified according to the Heidelberg bleeding classification on follow-up MRI or CT approximately 8 hours-7 days after stroke. Hemorrhage volume was measured with ITK-snap. Successful reperfusion was defined as extended Thrombolysis In Cerebral Infarction (eTICI) score of 2b-3. Multinomial and binary adjusted logistic regression were used to determine the association of IVT and reperfusion with ICH subtypes. RESULTS Of 539 included patients, 173 (32%) developed ICH and 30 suffered from symptomatic ICH (sICH) (6%). Of the patients with ICH, 102 had hemorrhagic infarction, 47 had parenchymal hematoma, 44 had SAH, and six had other ICH. Reperfusion was associated with a decreased risk of SAH, and IVT was not associated with SAH (eTICI 2b-3: adjusted OR 0.45, 95% CI 0.21 to 0.97; EVT without IVT: OR 1.6, 95% CI 0.91 to 2.8). Reperfusion status and IVT were not associated with overall ICH, hemorrhage volume, and sICH (sICH: EVT without IVT, OR 0.96, 95% CI 0.41 to 2.25; eTICI 2b-3, OR 0.49, 95% CI 0.23 to 1.05). CONCLUSION Neither IVT administration before EVT nor successful reperfusion after EVT were associated with ICH, hemorrhage volume, and sICH. SAH occurred more often in patients for whom successful reperfusion was not achieved.
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Affiliation(s)
- Katinka R van Kranendonk
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Agnetha A E Bruggeman
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Leon A Rinkel
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Kilian M Treurniet
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Radiology, Haaglanden Medical Center Bronovo, Den Haag, Zuid-Holland, The Netherlands
| | - Natalie LeCouffe
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Bart J Emmer
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Jonathan M Coutinho
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Lennard Wolff
- Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Wim H van Zwam
- Radiology, Maastricht University Cardiovascular Research Institute Maastricht, Maastricht, Limburg, The Netherlands
| | - Robert J van Oostenbrugge
- Neurology, Maastricht University Cardiovascular Research Institute Maastricht, Maastricht, Limburg, The Netherlands
| | - Aad van der Lugt
- Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | | | - Yvo B W E M Roos
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Henk A Marquering
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Biomedical Engineering and Physics, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
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11
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Cernigliaro M, Stanca C, Galbiati A, Spinetta M, Coda C, Negroni D, Laganà D, Minici R, Airoldi C, Carriero A, Guzzardi G. Innovation in Acute Ischemic Stroke Patients over 80 y/o-A Retrospective Monocentric Study on Mechanical Thrombectomy of Consecutive Patients: Is Age an Adequate Selection Criterion? J Clin Med 2023; 12:jcm12113688. [PMID: 37297883 DOI: 10.3390/jcm12113688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Although it is clear that stroke is a time-dependent and age-associated disease, we still need more evidence regarding the efficacy and outcomes in elderly patients who were excluded from the first trials of mechanical thrombectomy. The aim of this study is to highlight patient characteristics, the timing of medical attention and therapy, successful recanalization, and functional outcomes in patients over 80 y/o who underwent mechanical thrombectomy at the Ospedale Maggiore della Carità di Novara (Hub) since endovascular stroke treatment was first started here. METHODS all 122 consecutive patients over 80 y/o at admission who underwent mechanical thrombectomy between 2017 and 2022 at our Hub center were retrospectively included in our database. A good functional outcome in these elderly patients was considered as the 90 days modified Rankin Scale (mRS) ≤ 3 and/or a decrease in functional status as ∆mRS ≤ 1 in order to interpret the results for patients with intact intellect and basal mRS > 3. Successful recanalization as a score of TICI ≥ 2b (Thrombolysis in Cerebral Infarction) was analyzed as a secondary outcome. RESULTS Good functional outcome (mRS ≤ 3 and/or ∆mRS ≤ 1) was observed in 45.90% (56/122). The rate of successful recanalization (TICI ≥ 2b) was 65.57% (80/122). CONCLUSION Our data confirm that a good outcome in the elderly age group has a correlation with age; being younger, with a milder NIHSS (National Institutes of Health Stroke Scale) at the onset and with a lower pre-morbid mRS is statistically associated with a better outcome. However, age should not be a criterion to exclude older patients from mechanical thrombectomy. Decision-making should take into consideration the pre-morbid mRS and the severity of the stroke on the NIHSS scale, especially in the age group over 85 y/o.
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Affiliation(s)
- Massimiliano Cernigliaro
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Carmelo Stanca
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Andrea Galbiati
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Marco Spinetta
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Carolina Coda
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Davide Negroni
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Domenico Laganà
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Roberto Minici
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Chiara Airoldi
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Alessandro Carriero
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Giuseppe Guzzardi
- Radiodiagnostica ed Interventistica, Azienda Ospedaliero Universitaria Maggiore della Carità, 28100 Novara, Italy
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12
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Han B, Sun D, Raynald, Jia B, Tong X, Wang A, Mo D, Gao F, Ma N, Miao Z. Current status of endovascular treatment for older adults with acute large vessel occlusion stroke in China: subgroup analysis of ANGEL act registry. Front Neurol 2023; 14:1114556. [PMID: 37144005 PMCID: PMC10151760 DOI: 10.3389/fneur.2023.1114556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/15/2023] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Although endovascular treatment (EVT) has become the standard treatment for acute large vessel occlusion (LVO), its safety and efficacy in older adults have not been fully determined. The present study aimed to compare the safety and efficacy of EVT for acute LVO between younger (<80 years old) and older adults (≥80 years old) in the Chinese population. METHODS The subjects were selected from the ANGEL-ACT registry (endovascular treatment key technique and emergency workflow improvement of acute ischemic stroke). The 90-day modified Rankin score (mRS), successful recanalization, procedure duration, number of passes, intracranial hemorrhage (ICH), and mortality within 90 days were compared after adjusting for confounders. RESULTS A total of 1,691 patients, 1,543 classified as young and 148 classified as older, were included. We observed that young and older adults had a similar 90-day mRS distribution, successful recanalization, procedure duration, number of passes, ICH, and mortality within 90 days (all p > 0.05). The rate of 90-day mRS 0-3 was found to be higher in young patients than in older adults (39.9% vs. 56.5%, odds ratio = 0.64, 95% confidence interval = 0.44-0.94, p = 0.022). CONCLUSION We found that patients less than or greater than 80 years of age share similar clinical outcomes, without increasing the risk of ICH and mortality.
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Affiliation(s)
- Bin Han
- Shanxi Key Laboratory of Brain Disease Control, Department of Neurology, Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Bala F, Kim BJ, Najm M, Thornton J, Fainardi E, Michel P, Alpay K, Herlihy D, Goyal M, Casetta I, Nannoni S, Ylikotila P, Power S, Saia V, Hegarty A, Pracucci G, Rautio R, Ademola A, Demchuk A, Mangiafico S, Boyle K, Hill MD, Toni D, Murphy S, Menon BK, Almekhlafi MA. Outcomes with Endovascular Treatment of Patients with M2 Segment MCA Occlusion in the Late Time Window. AJNR Am J Neuroradiol 2023; 44:447-452. [PMID: 36958801 PMCID: PMC10084904 DOI: 10.3174/ajnr.a7833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/23/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Randomized trials in the late window have demonstrated the efficacy and safety of endovascular thrombectomy in large-vessel occlusions. Patients with M2-segment MCA occlusions were excluded from these trials. We compared outcomes with endovascular thrombectomy in patients with M2-versus-M1 occlusions presenting 6-24 hours after symptom onset. MATERIALS AND METHODS Analyses were on pooled data from studies enrolling patients with stroke treated with endovascular thrombectomy 6-24 hours after symptom onset. We compared 90-day functional independence (mRS ≤ 2), mortality, symptomatic intracranial hemorrhage, and successful reperfusion (expanded TICI = 2b-3) between patients with M2 and M1 occlusions. The benefit of successful reperfusion was then assessed among patients with M2 occlusion. RESULTS Of 461 patients, 367 (79.6%) had M1 occlusions and 94 (20.4%) had M2 occlusions. Patients with M2 occlusions were older and had lower median baseline NIHSS scores. Patients with M2 occlusion were more likely to achieve 90-day functional independence than those with M1 occlusion (adjusted OR = 2.13; 95% CI, 1.25-3.65). There were no significant differences in the proportion of successful reperfusion (82.9% versus 81.1%) or mortality (11.2% versus 17.2%). Symptomatic intracranial hemorrhage risk was lower in patients with M2-versus-M1 occlusions (4.3% versus 12.2%, P = .03). Successful reperfusion was independently associated with functional independence among patients with M2 occlusions (adjusted OR = 2.84; 95% CI, 1.11-7.29). CONCLUSIONS In the late time window, patients with M2 occlusions treated with endovascular thrombectomy achieved better clinical outcomes, similar reperfusion, and lower symptomatic intracranial hemorrhage rates compared with patients with M1 occlusion. These results support the safety and benefit of endovascular thrombectomy in patients with M2 occlusions in the late window.
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Affiliation(s)
- F Bala
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Diagnostic and Interventional Neuroradiology Department (F.B.), University Hospital of Tours, Tours, France
| | - B J Kim
- Department of Neurology and Cerebrovascular Center (B.J.K.), Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - M Najm
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - J Thornton
- Neuroradiology Department (J.T., D.H., S.P.)
- Royal College of Surgeons in Ireland (J.T., A.H.), Dublin, Ireland
| | - E Fainardi
- Neuroradiology Unit (E.F.), Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - P Michel
- Stroke Center (P.M., S.N.), Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - K Alpay
- Department of Radiology (K.A., R.R.), Turku University Hospital, Turku, Finland
| | - D Herlihy
- Neuroradiology Department (J.T., D.H., S.P.)
| | - M Goyal
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - I Casetta
- Clinica Neurologica (I.C.), University of Ferrara, Ferrara, Italy
| | - S Nannoni
- Stroke Center (P.M., S.N.), Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - P Ylikotila
- Neurocenter (P.Y.), Turku University Hospital, University of Turku, Turku, Finland
| | - S Power
- Neuroradiology Department (J.T., D.H., S.P.)
| | - V Saia
- Stroke Unit (V.S.), Santa Corona Hospital, Pietra Ligure, Italy
| | - A Hegarty
- Royal College of Surgeons in Ireland (J.T., A.H.), Dublin, Ireland
| | - G Pracucci
- Stroke Unit (G.P.), Careggi University Hospital, Florence, Italy
| | - R Rautio
- Department of Radiology (K.A., R.R.), Turku University Hospital, Turku, Finland
| | - A Ademola
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - A Demchuk
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - S Mangiafico
- Interventional Neuroradiology Unit (S. Mangiafico), Institute for Hospitalization and Healthcare Neuromed, Pozzilli, Italy
| | - K Boyle
- Department of Geriatric and Stroke Medicine (K.B.), Beaumont Hospital, Dublin, Ireland
| | - M D Hill
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - D Toni
- Emergency Department (D.T.), Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - S Murphy
- Department of Geriatric and Stroke Medicine (S. Murphy), The Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine (S. Murphy), Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine (S. Murphy), University College Dublin, Dublin, Ireland
| | - B K Menon
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - M A Almekhlafi
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
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14
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Barow E, Probst AC, Pinnschmidt H, Heinze M, Jensen M, Rimmele DL, Flottmann F, Broocks G, Fiehler J, Gerloff C, Thomalla G. Effect of Comorbidity Burden and Polypharmacy on Poor Functional Outcome in Acute Ischemic Stroke. Clin Neuroradiol 2023; 33:147-154. [PMID: 35831611 PMCID: PMC10014774 DOI: 10.1007/s00062-022-01193-8] [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: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Comorbidities and polypharmacy are risk factors for worse outcome in stroke. However, comorbidities and polypharmacy are mostly studied separately with various approaches to assess them. We aimed to analyze the impact of comorbidity burden and polypharmacy on functional outcome in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). METHODS Acute ischemic stroke patients with large vessel occlusion (LVO) treated with MT from a prospective observational study were analyzed. Relevant comorbidity burden was defined as a Charlson Comorbidity Index (CCI) score ≥ 2, polypharmacy as the intake of ≥ 5 medications at time of stroke onset. Favorable outcome was a score of 0-2 on the modified Rankin scale at 90 days after stroke. The effect of comorbidity burden and polypharmacy on favorable outcome was studied via multivariable regression analysis. RESULTS Of 903 patients enrolled, 703 AIS patients (mean age 73.4 years, 54.9% female) with anterior circulation LVO were included. A CCI ≥ 2 was present in 226 (32.1%) patients, polypharmacy in 315 (44.8%) patients. Favorable outcome was less frequently achieved in patients with a CCI ≥ 2 (47, 20.8% vs. 172, 36.1%, p < 0.001), and in patients with polypharmacy (69, 21.9% vs. 150, 38.7%, p < 0.001). In multivariable regression analysis including clinical covariates, a CCI ≥ 2 was associated with lower odds of favorable outcome (odds ratio, OR 0.52, 95% confidence interval, 95% CI 0.33-0.82, p = 0.005), while polypharmacy was not (OR 0.81, 95% CI 0.52-1.27, p = 0.362). CONCLUSION Relevant comorbidity burden and polypharmacy are common in AIS patients with LVO, with comorbidity burden being a risk factor for poor outcome.
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Affiliation(s)
- Ewgenia Barow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Ann-Cathrin Probst
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Hans Pinnschmidt
- Institut für Medizinische Biometrie und Epidemiologie, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Heinze
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - David Leander Rimmele
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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15
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Bretzner M, Bonkhoff AK, Schirmer MD, Hong S, Dalca A, Donahue K, Giese AK, Etherton MR, Rist PM, Nardin M, Regenhardt RW, Leclerc X, Lopes R, Gautherot M, Wang C, Benavente OR, Cole JW, Donatti A, Griessenauer C, Heitsch L, Holmegaard L, Jood K, Jimenez-Conde J, Kittner SJ, Lemmens R, Levi CR, McArdle PF, McDonough CW, Meschia JF, Phuah CL, Rolfs A, Ropele S, Rosand J, Roquer J, Rundek T, Sacco RL, Schmidt R, Sharma P, Slowik A, Sousa A, Stanne TM, Strbian D, Tatlisumak T, Thijs V, Vagal A, Wasselius J, Woo D, Wu O, Zand R, Worrall BB, Maguire J, Lindgren AG, Jern C, Golland P, Kuchcinski G, Rost NS. Radiomics-Derived Brain Age Predicts Functional Outcome After Acute Ischemic Stroke. Neurology 2023; 100:e822-e833. [PMID: 36443016 PMCID: PMC9984219 DOI: 10.1212/wnl.0000000000201596] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/06/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While chronological age is one of the most influential determinants of poststroke outcomes, little is known of the impact of neuroimaging-derived biological "brain age." We hypothesized that radiomics analyses of T2-FLAIR images texture would provide brain age estimates and that advanced brain age of patients with stroke will be associated with cardiovascular risk factors and worse functional outcomes. METHODS We extracted radiomics from T2-FLAIR images acquired during acute stroke clinical evaluation. Brain age was determined from brain parenchyma radiomics using an ElasticNet linear regression model. Subsequently, relative brain age (RBA), which expresses brain age in comparison with chronological age-matched peers, was estimated. Finally, we built a linear regression model of RBA using clinical cardiovascular characteristics as inputs and a logistic regression model of favorable functional outcomes taking RBA as input. RESULTS We reviewed 4,163 patients from a large multisite ischemic stroke cohort (mean age = 62.8 years, 42.0% female patients). T2-FLAIR radiomics predicted chronological ages (mean absolute error = 6.9 years, r = 0.81). After adjustment for covariates, RBA was higher and therefore described older-appearing brains in patients with hypertension, diabetes mellitus, a history of smoking, and a history of a prior stroke. In multivariate analyses, age, RBA, NIHSS, and a history of prior stroke were all significantly associated with functional outcome (respective adjusted odds ratios: 0.58, 0.76, 0.48, 0.55; all p-values < 0.001). Moreover, the negative effect of RBA on outcome was especially pronounced in minor strokes. DISCUSSION T2-FLAIR radiomics can be used to predict brain age and derive RBA. Older-appearing brains, characterized by a higher RBA, reflect cardiovascular risk factor accumulation and are linked to worse outcomes after stroke.
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Affiliation(s)
- Martin Bretzner
- From the J. Philip Kistler Stroke Research Center (M.B., A.K.B., M.D.S., S.H., A. Dalca, K.D., A.-K.G., M.R.E., P.M.R., M.N., R.W.R., C.W., N.S.R.), A.A. Martinos Center for Biomedical Imaging (A. Dalca, O.W.), and Henry and Allison McCance Center for Brain Health (J. Rosand), Massachusetts General Hospital, Harvard Medical School, Boston; Lille Neuroscience & Cognition (M.B., X.L., R. Lopes, G.K.), Inserm, CHU Lille, U1172 and Institut Pasteur de Lille (M.G.), CNRS, Inserm, CHU Lille, US 41 - UMS 2014 - PLBS, Lille University, France; Computer Science and Artificial Intelligence Lab (A. Dalca, C.W., P.G.), Massachusetts Institute of Technology, Cambridge; Division of Preventive Medicine (P.M.R.), Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Medicine (O.R.B.), Division of Neurology, University of British Columbia, Vancouver, Canada; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD; School of Medical Sciences (A. Donatti, A. Sousa), University of Campinas (UNICAMP) and the Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas, São Paulo; Departments of Neurosurgery (C.G.) and Neurology (R.Z.), Geisinger, Danville, PA; Department of Neurosurgery (C.G.), Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Division of Emergency Medicine (Laura Heitsch), Washington University School of Medicine, St. Louis; Department of Neurology (Laura Heitsch, C.-L.P.), Washington University School of Medicine & Barnes-Jewish Hospital, St. Louis, MO; Department of Clinical Neuroscience (L. Holmegaard, K.J., T.M.S., T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurology (J.J.-C.), Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions M`ediques), Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (R. Lemmens), Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND), KU Leuven - University of Leuven, Belgium; Department of Neurology (R. Lemmens), Laboratory of Neurobiology, VIB Vesalius Research Center, University Hospitals Leuven, Belgium; School of Medicine and Public Health (C.R.L.), University of Newcastle, New South Wales; Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia; Division of Endocrinology (P.F.M.), Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore; Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics (C.W.M.), University of Florida, Gainesville; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Klinik und Poliklinik für Neurologie (A.R.), Universitätsmedizin Rostock, Germany; Department of Neurology (S.R., R.S.), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Center for Genomic Medicine (J. Rosand), Massachusetts General Hospital, Boston; Broad Institute (J. Rosand), Cambridge, MA; Department of Neurology and Evelyn F. McKnight Brain Institute (J. Roquer, T.R., R.L.S./M.S.), Miller School of Medicine, University of Miami, FL; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London (ICR2UL), UK St Peter's and Ashford Hospitals, Egham, United Kingdom; Department of Neurology (A. Slowik), Jagiellonian University Medical College, Krakow, Poland; Division of Neurocritical Care & Emergency Neurology (D.S.), Department of Neurology, Helsinki University Central Hospital, Finland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Australia; Departments of Radiology (A.V.) and Neurology and Rehabilitation Medicine (D.W.), University of Cincinnati College of Medicine, OH; Department of Clinical Sciences Lund, Radiology (J.W.) and Neurology (A.G.L.), Lund University, Sweden; Department of Radiology, Neuroradiology, Skåne University Hospital, Malmö, Sweden; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville, VA; University of Technology Sydney (J.M.), Australia; Section of Neurology (A.G.L.), Skåne University Hospital, Lund, Sweden; Department of Laboratory Medicine (C.J.), Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg, Sweden; and Department of Clinical Genetics and Genomics (C.J.), Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden.
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16
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Lai YJ, Peng SH, Lai WJ, Li AH, Yen HH, Huang LW, Tang CW. Predictors of 30-day mortality after endovascular thrombectomy for large vessel occlusion in the elderly. Interv Neuroradiol 2023; 29:37-42. [PMID: 34967236 PMCID: PMC9893232 DOI: 10.1177/15910199211069259] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Elderly acute ischemic stroke (AIS) patients (≥80 years) would have dismal clinical outcomes even after successful endovascular revascularization for large vessel occlusion (LVO) in the anterior circulation. We aimed to identify predictors of 30-day mortality after endovascular thrombectomy (EVT) in the elderly. MATERIALS AND METHODS We included older patients who underwent EVT for AIS due to LVO within 6 h after stroke onset in the anterior circulation between 2017 and 2019. Patients due to posterior circulation stroke, with intracerebral hemorrhage (ICH) or pre-stroke modified Rankin Scale (mRS) score of 4 and 5 were excluded. The primary outcome was mortality within 30 days of EVT. The association between clinical, imaging, procedural, follow-up imaging and mortality were analyzed. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3. Possible predictors of 30-day mortality were assessed by univariate and multivariable logistic regression. RESULTS Total 238 AIS patients eligible for EVT were identified with 58 patients aged 80 years or more. 48 patients met inclusion criteria. Median age was 86 years (age range, 82-102 years). Successful reperfusion was achieved in 38 (79.2%) patients. The 30-day and 90-day mortality rate were 25% and 33.3%, respectively. The independent predictors of 30-day mortality were collateral scores <3 on mCTA (adjusted OR, 16.571; 95% CI, 1.041-263.868; p = 0.047) and number of passes (adjusted OR, 2.475; 95% CI, 1.047-5.847; p = 0.039). CONCLUSIONS Lower collateral scores on mCTA and higher number of passes in thrombectomy were independently predictive of 30-day mortality in the elderly.
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Affiliation(s)
- Yen-Jun Lai
- Department of Medical Imaging, Far Eastern Memorial
Hospital, New Taipei City
| | - Szu-Hsiang Peng
- Department of Medical Imaging, Far Eastern Memorial
Hospital, New Taipei City
| | - Wei-Jen Lai
- Department of Medical Imaging, Far Eastern Memorial
Hospital, New Taipei City
| | - Ai-Hsien Li
- Department of Cardiology, Far Eastern Memorial
Hospital, New Taipei City
| | - Ho-Hsian Yen
- Department of Medical Imaging, Far Eastern Memorial
Hospital, New Taipei City
| | - Lih-Wen Huang
- Department of Neurology, Far Eastern Memorial
Hospital, New Taipei City
| | - Chih-Wei Tang
- Department of Neurology, Far Eastern Memorial
Hospital, New Taipei City
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17
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Laugesen NG, Brandt AH, Stavngaard T, Højgaard J, Hansen K, Truelsen T. Mechanical thrombectomy in stroke patients of advanced age with score-based prediction of outcome. Interv Neuroradiol 2022:15910199221149073. [PMID: 36579806 DOI: 10.1177/15910199221149073] [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: 12/30/2022] Open
Abstract
BACKGROUND Stroke patients ≥80 years constituted only 15% in randomised trials on mechanical thrombectomy (MT), but is a considerable higher proportion in clinical practice. Association of clinical variables collected before MT with functional outcome has not been independently described in these patients, while being important in the decision of patient eligibility for MT. METHODS We included patients consecutively at a single centre (2017-2021) categorised as octogenarians (age: 80-89 years) or nonagenarians (age: 90-99 years). Functional outcome at 90 days was defined as fair (modified Rankin Scale (mRS) 0-3) or poor (mRS 4-6). Clinical variables collected before MT were analysed for association with shift of mRS in a poor direction. Significant predictors were used to produce a risk score of fair outcome. Significance was set at the p < 0.05 level. RESULTS Nonagenarians (n = 43, 15.5%) compared to octogenarians (n = 235, 84.5%) less likely achieved fair outcome (20.9% vs. 46.0%, p < 0.01) with higher mortality (65.1% vs. 31.9%, p < 0.01). Significant predictors of outcome were: age, adjusted odds ratio (aOR) = 0.91 (95% confidence interval (CI): 0.86-0.97); pre-stroke mRS, aOR = 0.57 (95% CI: 0.44-0.73); National Institute of Health Stroke Scale at admission, aOR = 0.91 (95% CI: 0.87-0.95); Alberta Stroke Program Early Computed Tomography, aOR = 1.23 (95% CI: 1.05-1.45). After bootstrap validation, the area under the curve of the risk score was 0.74 and the optimal cut-off for fair outcome was a score of >7 points. CONCLUSIONS One in two octogenarians achieved fair outcome, however, only one in five nonagenarians had fair outcome. The clinical risk score could be considered as guidance when deciding patient eligibility for MT.
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Affiliation(s)
| | - Andreas Hjelm Brandt
- Neurovascular Section, Department of Radiology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Trine Stavngaard
- Neurovascular Section, Department of Radiology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Joan Højgaard
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
- 53139Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Truelsen
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
- 53139Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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18
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Dunphy H, Garcia-Esperon C, Beom Hong J, Manoczki C, Wilson D, Lim Alvin Chew B, Beharry J, Bivard A, Hasnain MG, Krauss M, Collecutt W, Miteff F, Spratt N, Parsons MW, Alan Barber P, Ranta A, Fink JN, Wu TY. Endovascular thrombectomy for acute ischaemic stroke improves and maintains function in the very elderly: A multicentre propensity score matched analysis. Eur Stroke J 2022; 8:191-198. [PMID: 37021178 PMCID: PMC10069224 DOI: 10.1177/23969873221145778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/30/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction: The very elderly (⩾80 years) are under-represented in randomised endovascular thrombectomy (EVT) clinical trials for acute ischaemic stroke. Rates of independent outcome in this group are generally lower than the less-old patients but the comparisons may be biased by an imbalance of non-age related baseline characteristics, treatment related metrics and medical risk factors. Patients and methods: We compared outcomes between very elderly (⩾80) and the less-old (<80 years) using retrospective data from consecutive patients receiving EVT from four comprehensive stroke centres in New Zealand and Australia. We used propensity score matching or multivariable logistic regression to account for confounders. Results: We included 600 patients (300 in each age cohort) after propensity score matching from an initial group of 1270 patients. The median baseline National Institutes of Health Stroke Scale was 16 (11–21), with 455 (75.8%) having symptom free pre-stroke independent function, and 268 (44.7%) receiving intravenous thrombolysis. Good functional outcome (90-day modified Rankin Scale 0–2) was achieved in 282 (46.8%), with very elderly patients having less proportion of good outcome compared to the less-old (118 (39.3%) vs 163 (54.3%), p < 0.01). There was no difference between the very elderly and the less-old in the proportion of patients who returned to baseline function at 90 days (56 (18.7%) vs 62 (20.7%), p = 0.54). All-cause 90-day mortality was higher in the very elderly (75 (25%) vs 49 (16.3%), p < 0.01), without a difference in symptomatic haemorrhage (very elderly 11 (3.7%) vs 6 (2.0%), p = 0.33). In the multivariable logistic regression models, the very elderly were significantly associated with reduced odds of good 90-day outcome (OR 0.49, 95% CI 0.34–0.69, p < 0.01) but not with return to baseline function (OR 0.85, 90% CI 0.54–1.29, p = 0.45) after adjusting for confounders. Conclusion: Endovascular thrombectomy can be successfully and safely performed in the very elderly. Despite an increase in all-cause 90-day mortality, selected very elderly patients are as likely as younger patients with similar baseline characteristics to return to baseline function following EVT.
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Affiliation(s)
- Harriette Dunphy
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
- Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Jae Beom Hong
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Csilla Manoczki
- Department of Neurology, Wellington Hospital, University of Otago, Wellington, New Zealand
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | | | - James Beharry
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Md Golam Hasnain
- Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Martin Krauss
- Department of Radiology, Christchurch Hospital, New Zealand
| | | | - Ferdi Miteff
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
- Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
- The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, NSW, Australia
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
- University of New South Wales South Western Sydney Clinical Campus, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Peter Alan Barber
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
- Centre for Brain Research, University of Auckland, Auckland, New Zealand
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, University of Otago, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - John N Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
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19
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Quandt F, Meißner N, Wölfer TA, Flottmann F, Deb-Chatterji M, Kellert L, Fiehler J, Goyal M, Saver JL, Gerloff C, Thomalla G, Tiedt S. RCT versus real-world cohorts: Differences in patient characteristics drive associations with outcome after EVT. Eur Stroke J 2022; 8:231-240. [PMID: 37021166 PMCID: PMC10069173 DOI: 10.1177/23969873221142642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
Background: The selection of patients with large-vessel occlusion (LVO) stroke for endovascular treatment (EVT) depends on patient characteristics and procedural metrics. The relation of these variables to functional outcome after EVT has been assessed in numerous datasets from both randomized controlled trials (RCT) and real-world registries, but whether differences in their case mix modulate outcome prediction is unknown. Methods: We leveraged data from individual patients with anterior LVO stroke treated with EVT from completed RCTs from the Virtual International Stroke Trials Archive ( N = 479) and from the German Stroke Registry ( N = 4079). Cohorts were compared regarding (i) patient characteristics and procedural pre-EVT metrics, (ii) these variables’ relation to functional outcome, and (iii) the performance of derived outcome prediction models. Relation to outcome (functional dependence defined by a modified Rankin Scale score of 3–6 at 90 days) was analyzed by logistic regression models and a machine learning algorithm. Results: Ten out of 11 analyzed baseline variables differed between the RCT and real-world cohort: RCT patients were younger, had higher admission NIHSS scores, and received thrombolysis more often (all p < 0.0001). Largest differences at the level of individual outcome predictors were observed for age (RCT: adjusted odds ratio (aOR), 1.29 (95% CI, 1.10–1.53) vs real-world aOR, 1.65 (95% CI, 1.54–1.78) per 10-year increments, p < 0.001). Treatment with intravenous thrombolysis was not significantly associated with functional outcome in the RCT cohort (aOR, 1.64 (95 % CI, 0.91–3.00)), but in the real-world cohort (aOR, 0.81 (95% CI, 0.69–0.96); p for cohort heterogeneity = 0.056). Outcome prediction was more accurate when constructing and testing the model using real-world data compared to construction with RCT data and testing on real-world data (area under the curve, 0.82 (95% CI, 0.79–0.85) vs 0.79 (95% CI, 0.77–0.80), p = 0.004). Conclusions: RCT and real-world cohorts considerably differ in patient characteristics, individual outcome predictor strength, and overall outcome prediction model performance.
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Affiliation(s)
- Fanny Quandt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nina Meißner
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Teresa A Wölfer
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
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20
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Tiainen M, Martinez-Majander N, Virtanen P, Räty S, Strbian D. Clinical frailty and outcome after mechanical thrombectomy for stroke in patients aged ≥ 80 years. J Stroke Cerebrovasc Dis 2022; 31:106816. [PMID: 36215902 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Data concerning the results of endovascular thrombectomy (EVT) in old patients is still limited. We aimed to investigate the outcomes in thrombectomy-treated ischemic stroke patients aged ≥ 80 years, focusing on frailty as a contributing factor. PATIENTS AND METHODS We performed a single-centre retrospective cohort study with 159 consecutive patients aged ≥ 80 years and treated with EVT for acute ischemic stroke between January 1st 2016 and December 31st 2019. Pre-admission frailty was assessed with the Clinical Frailty Scale (CFS). Patients with CFS ≥ 5 were defined as frail. The main outcome was very poor outcome defined as mRS 4-6 at three months after EVT. Secondary outcomes were recanalization status, symptomatic intracerebral haemorrhage (sICH), and one-year survival. Finally, we recorded if the patient returned home within 12 months. RESULTS Very poor outcome was observed in 57.9% of all patients (52.4% in non-frail and 79.4% in frail patients). Rates of recanalization and sICH were comparable in frail and non-frail patients. Of all patients, 46.5% were able to live at home within 1 year after stroke. One-year survival was 59.1% (65.6% in non-frail and 35.3% in frail patients). In logistic regression analysis higher admission NIHSS, not performing thrombolysis, lack of recanalization and higher frailty status were all independently associated with very poor three-month outcome. Factors associated with one-year mortality were male gender, not performing thrombolysis, sICH, and higher frailty status. CONCLUSION Almost 60% of studied patients had very poor outcome. Frailty significantly increases the likelihood of very poor outcome and death after EVT-treated stroke.
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21
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Rezai MK, Dalen I, Advani R, Fjetland L, Kurz KD, Sandve KO, Kurz MW. Thrombectomy in large vessel occlusion stroke-Does age matter? Acta Neurol Scand 2022; 146:628-634. [PMID: 36029034 PMCID: PMC9804277 DOI: 10.1111/ane.13691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Endovascular treatment (EVT) is the gold standard treatment for emergent large vessel occlusion (LVO). The benefit of EVT for emergent LVO in elderly patients (>80 years old) is still debated as they have been under-represented in randomized controlled trials. Elderly patients with an emergent LVO are a growing population warranting further study. MATERIALS & METHODS We included 225 consecutive patients treated with EVT for LVO either in the anterior or posterior circulation. The clinical outcome was assessed using the National Institute of Health Stroke Scale (NIHSS). Long-term functional outcome was assessed using 90-day modified ranking scale (mRS). RESULTS Neurological improvement: A five-year higher age predicted a 0.43 higher mean NIHSS score after EVT (p = .027). After adjusting for confounders (influencing variables), the association between age and post-interventional NIHSS was reduced and non-significant (p = .17). At discharge, a five-year higher age predicted a 0.74 higher mean NIHSS (p = .003). After adjusting for confounders this association was reduced and non-significant (p = .06). Long-term functional outcome: A five-year higher age predicted a 0.20 higher mRS at three months (p < .001). When adjusting for confounders this number was reduced to 0.16, yet still highly significant (p < .001). CONCLUSIONS Age seems to have a minor role in predicting neurological improvement after EVT but has an impact on long-term functional outcome. The decision to perform or withhold EVT should therefore not solely be based on age.
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Affiliation(s)
- Mehdi K. Rezai
- Department of NeurologyStavanger University HospitalStavangerNorway,Neuroscience Research GroupStavanger University HospitalStavangerNorway
| | - Ingvild Dalen
- Department of Research, Section of BiostatisticsStavanger University HospitalStavangerNorway
| | - Rajiv Advani
- Neuroscience Research GroupStavanger University HospitalStavangerNorway,Department of Neurology, Stroke UnitOslo University HospitalOsloNorway
| | - Lars Fjetland
- Stavanger Medical Imaging Laboratory (SMIL), Department of RadiologyStavanger University HospitalStavangerNorway,Department of Electrical and Computer EngineeringUniversity of StavangerStavangerNorway
| | - Kathinka D. Kurz
- Stavanger Medical Imaging Laboratory (SMIL), Department of RadiologyStavanger University HospitalStavangerNorway,Department of Electrical and Computer EngineeringUniversity of StavangerStavangerNorway
| | - Knut Olav Sandve
- Stavanger Medical Imaging Laboratory (SMIL), Department of RadiologyStavanger University HospitalStavangerNorway
| | - Martin W. Kurz
- Department of NeurologyStavanger University HospitalStavangerNorway,Neuroscience Research GroupStavanger University HospitalStavangerNorway,Department of Clinical ScienceUniversity of BergenBergenNorway
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22
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Mechanical Thrombectomy for Acute Ischemic Stroke in Patients with Malignancy: A Systematic Review. J Clin Med 2022; 11:jcm11164696. [PMID: 36012933 PMCID: PMC9410462 DOI: 10.3390/jcm11164696] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Ischemic stroke is a common occurrence in patients with concomitant malignancy. Systemic thrombolysis is often contraindicated in these patients, and mechanical thrombectomy (MT) is the preferred method of intervention. This review aims to collect the available data on the safety and efficacy of MT in cancer patients (CPs).Methods: The PubMed/MEDLINE and SCOPUS databases were systematically searched for studies assessing safety (mortality, intracranial hemorrhage) and efficacy (reperfusion, functional outcome) indices in CPs receiving MT. Potentially relevant parameters examined in solitary studies were also extracted (e.g., stroke recurrence, brain malignancy).Results: A total of 18 retrospective studies of various methodologies and objectives were identified. Rates of in-hospital mortality, intracranial hemorrhage of any kind, reperfusion rates, and discharge condition did not seem to present any considerable differences between CPs and patients without cancer. On the contrary, 90-day mortality was higher and 90-day functional independence was lower in CPs. Three studies on cancer-related stroke (no other identifiable etiology and high D-dimer levels in the presence of active cancer) showed constant tendencies towards unfavorable conditions. Conclusions: Per the available evidence, MT appears to be a safe treatment option for CPs. It is still unclear whether the 90-day mortality and outcome rates are more heavily influenced by the malignancy and not the intervention itself, so MT can be considered in CPs with prospects of a good functional recovery, undertaking an individualized approach.
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23
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Stolp J, Coutinho JM, Immink RV, Preckel B. Anesthetic considerations for endovascular treatment in stroke therapy. Curr Opin Anaesthesiol 2022; 35:472-478. [PMID: 35787587 DOI: 10.1097/aco.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The introduction of clot removement by endovascular treatment (EVT) in 2015 has improved the clinical outcome of patients with acute ischemic stroke (AIS) due to a large vessel occlusion (LVO). Anesthetic strategies during EVT vary widely between hospitals, with some departments employing local anesthesia (LA), others performing conscious sedation (CS) or general anesthesia (GA). The optimal anesthetic strategy remains debated. This review will describe the effects of anesthetic strategy on clinical and radiological outcomes and hemodynamic parameters in patients with AIS undergoing EVT. RECENT FINDINGS Small single-center randomized controlled trails (RCTs) found either no difference or favored GA, while large observational cohort studies favored CS or LA. RCTs using LA as separate comparator arm are still lacking and a meta-analysis of observational studies failed to show differences in functional outcome between LA vs. other anesthetic strategies. Advantages of LA were shorter door-to-groin time in patients and less intraprocedural hypotension, which are both variables that are known to impact functional outcome. SUMMARY The optimal anesthetic approach in patients undergoing EVT for stroke therapy is still unclear, but based on logistics and peri-procedural hemodynamics, LA may be the optimal choice. Multicenter RCTs are warranted comparing LA, CS and GS with strict blood pressure targets and use of the same anesthetic agents to minimize confounding variables.
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Affiliation(s)
| | | | - Rogier V Immink
- Department of Anesthesiology, Amsterdam UMC Location AMC, University of Amsterdam
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam UMC Location AMC, University of Amsterdam
- Amsterdam Public Health, Quality of Care
- Amsterdam Cardiovascular Science, Diabetes & Metabolism, Amsterdam, The Netherlands
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24
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McDonough RV, Ospel JM, Campbell BCV, Hill MD, Saver JL, Dippel DWJ, Demchuk AM, Majoie CBLM, Brown SB, Mitchell PJ, Bracard S, Guillemin F, Jovin TG, Muir KW, White P, Goyal M. Functional Outcomes of Patients ≥85 Years With Acute Ischemic Stroke Following EVT: A HERMES Substudy. Stroke 2022; 53:2220-2226. [PMID: 35703094 DOI: 10.1161/strokeaha.121.037770] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Observational studies have shown endovascular treatment (EVT) for acute ischemic stroke to be effective in the elderly, despite resulting in poorer outcomes and higher rates of mortality compared with younger patients. Randomized data on the effect of advanced age on outcomes following EVT are, however, lacking. Our aim was to assess the EVT effect for ischemic stroke in patients aged ≥85 years and the influence of age on outcome in a large, randomized trial dataset. METHODS Data were from the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration, a meta-analysis of 7 randomized trials published between January 1, 2010, and May 31, 2017, that tested the efficacy of EVT. A possible multiplicative interaction effect of age on the relationship between treatment and outcome was investigated. Ordinal logistic regression tested the association between EVT and 90-day functional outcome (modified Rankin Scale, primary outcome) in patients ≥85 years. Multivariable binary logistic regression was performed to compare primary and secondary outcomes (modified Rankin Scale score of 0-2/5-6) of patients ≥85 years versus those <85 years. RESULTS We included 1764 patients in the analysis, of whom 77 (4.4%) were ≥85 years old. A significant interaction of age and treatment on poor outcome (modified Rankin Scale score of 5-6, P=0.020) and mortality (P=0.031) was observed, with older adults having worse functional outcomes at 90 days compared with younger patients (adjusted common odds ratio, 0.20 [95% CI, 0.13-0.33]). However, a benefit of EVT was observed in the ≥85-year-old patient subgroup (common odds ratio, 4.20 [95% CI, 1.56-11.32]). Age ≥85 years was not significantly associated with differing rates of symptomatic intracerebral hemorrhage or reperfusion (adjusted odds ratio, 1.92 [95% CI, 0.71-5.15] and adjusted odds ratio, 0.91 [95% CI, 0.40-2.06], respectively). CONCLUSIONS Patients ≥85 years old with independent premorbid function more often achieve good functional outcomes and have lower rates of mortality when treated with EVT compared with conservative management, with an observed treatment effect modification of age on outcome. EVT should therefore not be withheld in this subgroup.
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Affiliation(s)
- Rosalie V McDonough
- Department of Diagnostic Imaging (R.V.M., J.M.O.), Foothills Medical Center, University of Calgary, AB, Canada.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (R.V.M.)
| | - Johanna M Ospel
- Department of Diagnostic Imaging (R.V.M., J.M.O.), Foothills Medical Center, University of Calgary, AB, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Australia (B.C.V.C.)
| | - Michael D Hill
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles Medical Center (J.L.S.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands (D.W.J.D.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands (C.B.L.M.M.)
| | - Scott B Brown
- BRIGHT Research Partners, Inc, Mooresville, NC (S.B.B.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia (P.J.M.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology (S.B.), University of Lorraine and University Hospital of Nancy, France
| | - Francis Guillemin
- Department of Clinical Epidemiology (F.G.), University of Lorraine and University Hospital of Nancy, France
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center Stroke Institute, Presbyterian University Hospital, PA (T.G.J.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (K.W.M.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
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25
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Hu J, Liu X, Liu S, Sang H, Huang J, Luo W, Wang J, Chen Z, Yang S, He W, Zhang B, Yu Z, Wang S, Wen H, Zhu X, Sun R, Yang J, Li L, Song J, Tian Y, Qiu Z, Li F, Zi W, Tian Y, Yang D. Outcomes of Endovascular Therapy in Young Patients with Acute Basilar Artery Occlusion: A Substudy of BASILAR Registry Study. Neurol Ther 2022; 11:1519-1532. [PMID: 35705888 DOI: 10.1007/s40120-022-00372-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 05/27/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION This study aimed to investigate clinical outcomes in young patients with basilar artery occlusion (BAO) receiving endovascular therapy (EVT). METHODS Consecutive patients with BAO within 24 h who underwent EVT from the BASILAR Registry study were enrolled. We compared clinical outcomes of young patients (aged 18-55 years) with older patients (aged > 55 years) with stroke due to BAO at 90 days and 1 year after EVT. The primary and secondary outcomes were improvement in modified Rankin scale scores (mRS) at 90 days and either favorable (mRS 0-3) or mortality at 90 days, respectively. RESULTS A total of 646 patients were included, of which 152 (23.53%) were aged 18-55 years. Dyslipidemia (42.11% vs. 30.36%, p = 0.007) and good collateral circulation (60.52% vs. 46.35%, p = 0.002) were more frequent in young patients than older. Stroke etiologies in young patients included large artery atherosclerosis (67.11%), cardioembolism (15.13%), and vessel dissection (5.26%). Young patients were associated with better prognosis (mRS: adjusted odds ratio (aOR) 1.73; 95% confidence interval [CI] 1.21-2.48; mRS 0-3: aOR 1.60; 95% CI 1.01-2.54; mortality: aOR 0.60; 95% CI 0.38-0.93) at 90 days. Baseline National Institutes of Health Stroke Scale (NIHSS) score, posterior circulation Alberta Stroke Program Early Computed Tomography Score (pc-ASPECTS), and sex were independent predictors of clinical outcomes of young patients at 90 days after EVT. CONCLUSION Young patients with BAO had better clinical outcomes after EVT than old patients. Predictors of clinical outcomes in young patients undergoing EVT included baseline NIHSS score, pc-ASPECTS, and sex. TRIAL REGISTRATION Clinical Trial Registration-URL: ChiCTR180001475 ( www.chictr.org.cn ).
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Affiliation(s)
- Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Xing Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Jie Wang
- Department of Neurology, People's Hospital of Chongqing Banan District, Chongqing, 400037, China
| | - Zhuo Chen
- Department of Neurology, Mianzhu Hospital, West China Hospital of Sichuan University, Mianzhu, 618200, China
| | - Shuang Yang
- Department of Neurology, People's Hospital of Zunyi City Bo Zhou District, Zunyi, 563000, China
| | - Wencheng He
- Department of Neurology, GuiPing People's Hospital, GuiPing, 537200, China
| | - Bo Zhang
- Department of Neurology, Suining First People's Hospital, Suining, 629000, China
| | - Zhou Yu
- Department of Neurology, The First People's Hospital of Liangshan Yi Autonomous Prefecture, Xichang, 615000, China
| | - Shan Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, 400000, China
| | - Hongbin Wen
- Department of Neurology, Xiangyang Central Hospital, Hubei Arts and Science University, Xiangyang, 441100, China
| | - Xiurong Zhu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, 611200, China
| | - Ruidi Sun
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Yan Tian
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Zhongming Qiu
- Department of Neurology, The 903th Hospital of The People's Liberation Army, Hangzhou, 310007, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China.,Department of Neurology, Guangyang Bay Laboratory, Chongqing Institute for Brain and Intelligence, Chongqing, 400064, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China.,Department of Neurology, Guangyang Bay Laboratory, Chongqing Institute for Brain and Intelligence, Chongqing, 400064, China
| | - Yaoyu Tian
- Department of Neurology, Qian Xi Nan People's Hospital, No. B6 Road, Jukang Road, Jushan Office, Xingyi City, 562400, Buyi and Miao Autonomous Prefecture, Qianxinanzhou, China.
| | - De Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China. .,Department of Neurology, Chongqing University Fuling Hospital, No. 2 Gaozhutang Road, Fuling District, Fuling, 408000, China.
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Adcock AK, Schwamm LH, Smith EE, Fonarow GC, Reeves MJ, Xu H, Matsouaka RA, Xian Y, Saver JL. Trends in Use, Outcomes, and Disparities in Endovascular Thrombectomy in US Patients With Stroke Aged 80 Years and Older Compared With Younger Patients. JAMA Netw Open 2022; 5:e2215869. [PMID: 35671055 PMCID: PMC9175073 DOI: 10.1001/jamanetworkopen.2022.15869] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Patients aged 80 years and older were often excluded or underrepresented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis. OBJECTIVE To delineate temporal trends in EVT use, outcomes, and disparities among patients with acute ischemic stroke aged 80 years and older vs those younger than 80 years. DESIGN, SETTING, AND PARTICIPANTS A US nationwide retrospective cohort study using prospectively collected data was conducted in patients admitted with a primary diagnosis of acute ischemic stroke between April 1, 2012, and June 30, 2019. Data were obtained from hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, which is a stroke quality improvement registry, with data collected prospectively, sponsored by the American Heart Association/American Stroke Association. Data analysis was conducted from November 2, 2020, to June 25, 2021. EXPOSURES Potentially eligible for EVT based on arrival within 6 hours and National Institutes of Health Stroke Scale score greater than or equal to 6. MAIN OUTCOMES AND MEASURES Efficacy outcomes included discharge to home, independent ambulation at discharge, and functional independence (modified Rankin Scale score 0-2) at discharge. Safety outcomes included in-hospital mortality, combined in-hospital mortality or discharge to hospice, and symptomatic intracranial hemorrhage. RESULTS Among 302 965 patients with ischemic stroke meeting study criteria as potentially eligible for EVT admitted to 614 GWTG-Stroke hospitals, 14.0% (42 422) received EVT (21 634 women [51.0%]), including 10.7% (12 768 of 119 453) of patients aged 80 years and older (median [IQR] age, 85 [82-89] years) and 16.2% (29 654 of 183 512) of patients younger than 80 years (median [IQR] age, 65 [56-73] years). Among patients aged 80 years and older, EVT rates increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. By study end, the relative rate of EVT among eligible patients aged 80 years and older compared with those younger than 80 years increased from 0.49 (3.3% vs 6.7%) to 0.76 (20.8% vs 27.3%). Older patients had worse outcomes at discharge compared with younger patients, including discharge to home: 12.5% vs 31.1% (adjusted odds ratio [aOR], 0.43; 95% CI, 0.40-0.46), functional independence (modified Rankin Scale score 0-2): 10.9% vs 26.6% (aOR, 0.45; 95% CI, 0.41-0.49), and inpatient death or discharge to hospice, 34.5% vs 16.1% (aOR, 2.22; 95% CI, 2.09-2.36). Symptomatic intracranial hemorrhage rates did not differ significantly (6.9% vs 6.5%; aOR, 1.04; 95% CI, 0.94-1.14). CONCLUSIONS AND RELEVANCE In this cohort study, use of EVT among individuals aged 80 years and older increased substantially from 2012 to 2019, although the rate remained lower than in younger patients. Although favorable functional outcomes at discharge were lower and combined mortality or discharge to hospice was higher in the older patients, the risk of symptomatic intracranial hemorrhage was not increased.
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Affiliation(s)
- Amelia K. Adcock
- Department of Neurology, West Virginia University School of Medicine, Morgantown
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eric E. Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles
- Section Editor, Health Care Quality and Guidelines, JAMA Cardiology
| | - Mathew J. Reeves
- Department of Epidemiology, Michigan State University, East Lansing
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Ying Xian
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Benali F, Kappelhof M, Ospel J, Ganesh A, McDonough RV, Postma AA, Goldhoorn RJB, Majoie CBLM, van den Wijngaard I, Lingsma HF, Vos JA, van Oostenbrugge RJ, van Zwam WH, Goyal M. Benefit of successful reperfusion achieved by endovascular thrombectomy for patients with ischemic stroke and moderate pre-stroke disability (mRS 3): results from the MR CLEAN Registry. J Neurointerv Surg 2022; 15:433-438. [PMID: 35414601 DOI: 10.1136/neurintsurg-2022-018853] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pre-stroke dependent patients (modified Rankin Scale score (mRS) ≥3) were excluded from most trials on endovascular treatment (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Therefore, little evidence exists for EVT in those patients. We aimed to investigate the safety and benefit of EVT in pre-stroke patients with mRS score 3. METHODS We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic stroke in the Netherlands (MR CLEAN) Registry. All patients treated with EVT for anterior circulation AIS with pre-stroke mRS 3 were included. We assessed causes for dependence and compared patients with successful reperfusion (defined as expanded Thrombolysis in Cerebral Ischemia scale (eTICI) 2b-3) to patients without successful reperfusion. We used regression analyses with pre-specified adjustments. Our primary outcome was 90-day mRS 0-3 (functional improvement or return to baseline). RESULTS A total of 192 patients were included, of whom 82 (43%) had eTICI <2b and 108 (56%) eTICI ≥2b. The median age was 80 years (IQR 73-87). Fifty-one of the 192 patients (27%) suffered from previous stroke and 36/192 (19%) had cardiopulmonary disease. Patients with eTICI ≥2b more often returned to their baseline functional state or improved (n=26 (26%) vs n=15 (19%); adjusted odds ratio (aOR) 2.91 (95% CI 1.08 to 7.82)) and had lower mortality rates (n=49 (49%) vs n=50 (64%); aOR 0.42 (95% CI 0.19 to 0.93)) compared with patients with eTICI <2b. CONCLUSIONS Although patients with AIS with pre-stroke mRS 3 comprise a heterogenous group of disability causes, we observed improved outcomes when patients achieved successful reperfusion after EVT.
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Affiliation(s)
- Faysal Benali
- Radiology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands.,Departments of Clinical Neurosciences and Community Health Sciences and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Johanna Ospel
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Aravind Ganesh
- Departments of Clinical Neurosciences and Community Health Sciences and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rosalie V McDonough
- Departments of Clinical Neurosciences and Community Health Sciences and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Alida A Postma
- Radiology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | | | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | | | - Hester F Lingsma
- Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Albert Vos
- Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Wim H van Zwam
- Radiology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Mayank Goyal
- Departments of Clinical Neurosciences and Community Health Sciences and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Duloquin G, Ferrigno M, Hassen WB, Kyheng M, Bricout N, Boulouis G, Seners P, Labreuche J, Turc G, Naggara O, Cordonnier C, Henon H, Pasi M. Pre-treatment lesional volume in older stroke patients treated with endovascular treatment. Int J Stroke 2022; 17:1085-1092. [PMID: 35225745 DOI: 10.1177/17474930211068657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies in the general stroke population treated with endovascular treatment (EVT) reported that higher pre-treatment lesional volumes were independently associated with poor neurological outcome and functional dependence after stroke. However, it has been not evaluated in older patients. AIM We test the association between the pre-treatment lesional volume on diffusion-weighted magnetic resonance imaging and relevant outcome measures in older adults with stroke treated with EVT. METHODS We included consecutive older adults with stroke (⩾80 years old) treated with EVT in two academic comprehensive stroke centers. The association between pre-treatment lesional volume and relevant outcome measures (poor outcome (modified Rankin scale 4-6), 3-month mortality and symptomatic intracerebral hemorrhage (sICH)) was evaluated using univariate and multivariable models. RESULTS Five hundred seventy-nine patients were included (mean age: 85.6 ± 4.1, median lesional volume was 10 ml; interquartile range: 3-30 ml). Pre-treatment lesional volume was associated with poor functional outcome (adjusted odds ratio (aOR): 1.87, 95% confidence interval (CI): 1.60-2.20, for +1 logarithmic increase of lesional volume), 3-month mortality (aOR: 1.50, CI: 1.28-1.76), and sICH (aOR: 1.67, CI: 1.27-2.20). A threshold lesional volume >35 ml predicted 90% of patients with poor functional outcome and a cut-off >51 ml predicted 90% of patients dead at 3 months. CONCLUSIONS Pre-treatment lesional volume might contribute, in association with other relevant clinical features, to the selection of older stroke patients who will benefit from EVT.
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Affiliation(s)
- Gauthier Duloquin
- EA7460, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University Hospital of Dijon, University of Burgundy, Dijon, France
| | - Marc Ferrigno
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Wagih Ben Hassen
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Maéva Kyheng
- Département de Biostatistiques, CHU Lille, Lille, France.,University of Lille, CHU Lille, ULR 2694-METRICS: évaluation des technologies de santé et des pratiques médicales, Lille, France
| | | | - Grégoire Boulouis
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Pierre Seners
- Université de Paris, Inserm U1266, GHU Paris Psychiatrie et Neurosciences (Department of Neurology), FHU NeuroVasc, Paris, France
| | | | - Guillaume Turc
- Université de Paris, Inserm U1266, GHU Paris Psychiatrie et Neurosciences (Department of Neurology), FHU NeuroVasc, Paris, France
| | - Olivier Naggara
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Charlotte Cordonnier
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Hilde Henon
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Marco Pasi
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
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29
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Verschoof MA, Groot AE, de Bruijn SFTM, Roozenbeek B, Bart van der Worp H, Dippel DWJ, Emmer BJ, Roosendaal SD, Majoie CBLM, Roos YBWM, Coutinho JM. Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy. Neurology 2022; 98:e993-e1001. [PMID: 35017306 DOI: 10.1212/wnl.0000000000013316] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 12/28/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore clinical and safety outcomes of patients with acute ischemic stroke (AIS) and active cancer after endovascular treatment (EVT). METHODS Using data from the MR CLEAN Registry, we compared patients with active cancer (defined as cancer diagnosed within 12 months prior to stroke, metastatic disease, or current cancer treatment) to patients without cancer. Outcomes were 90-day modified Rankin Scale (mRS) score, mortality, successful reperfusion (eTICI scores≥2b), symptomatic intracranial hemorrhage (sICH), and recurrent stroke. Subgroup analyses were performed in patients with a pre-stroke mRS score of 0 or 1 and according to treatment setting (curative or palliative). Analyses were adjusted for prognostic variables. RESULTS Of 2583 patients who underwent EVT, 124 (4.8%) had active cancer. They more often had pre-stroke disability (mRS≥2: 34.1% vs. 16.6%). The treatment setting was palliative in 25.3% of the patients. There was a shift towards worse functional outcome at 90 days in patients with active cancer (adjusted common OR 2.2, 95% CI 1.5-3.2). At 90 days, patients with active cancer were less often independent (mRS 0-2: 22.6% vs. 42.0%, aOR 0.5, 95% CI 0.3-0.8), and more often dead (52.2% vs. 26.5%, aOR 3.2, 95% CI 2.1-4.9). Successful reperfusion (67.8% vs. 60.5%, aOR 1.4, 95% CI 1.0-2.1) and sICH rates (6.5% vs. 5.9%, aOR 1.1, 95 %CI 0.5-2.3) did not differ. Recurrent stroke within 90 days was more common in patients with active cancer (4.0% vs. 1.3%, aOR 3.1, 95% CI 1.2-8.1). The sensitivity analysis of patients with a pre-stroke mRS of 0 or 1 showed that patients with active cancer still had a worse outcome at 90 days (acOR 1.9, 95% CI 1.2-3.0). Patients with active cancer in a palliative treatment setting regained functional independence less often compared to patients in a curative setting (18.2% vs. 32.1%) and mortality was also higher (81.8% vs. 39.3%). CONCLUSIONS Despite similar technical success, patients with active cancer had significantly worse outcomes after EVT for AIS. Moreover, they had an increased risk of recurrent stroke. Nevertheless, about a quarter of the patients regained functional independence and the risk of other complications, most notably sICH, was not increased. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that patients with active cancer undergoing EVT for AIS have worse functional outcomes at 90 days compared to those without active cancer.
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Affiliation(s)
| | - Adrien E Groot
- Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam
| | | | | | | | | | - Bart Jeroen Emmer
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Stefan D Roosendaal
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Yvo B W M Roos
- Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam
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30
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Yogendrakumar V, Churilov L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu TY, Shah DG, Ng FC, Dewey HM, Wijeratne T, Yan B, Desmond PM, Parsons MW, Donnan GA, Davis SM, Campbell BCV. Safety and Efficacy of Tenecteplase in Older Patients With Large Vessel Occlusion: A Pooled Analysis of the EXTEND-IA TNK Trials. Neurology 2022; 98:e1292-e1301. [PMID: 35017305 DOI: 10.1212/wnl.0000000000013302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Detailed study of tenecteplase (TNK) in patients greater than 80 years of age is limited. The objective of our study was to assess the safety and efficacy of TNK at 0.25 and 0.40 mg/kg doses in patients greater than 80 years with large vessel occlusion. METHODS A pooled analysis of the EXTEND-IA TNK randomized controlled trials (n=502). Patients were adults presenting with ischemic stroke due to occlusion of the intracranial internal carotid, middle cerebral, or basilar artery presenting within 4.5 hours of symptom onset. We compared the treatment effect of TNK 0.25mg/kg, TNK 0.40mg/kg, and alteplase 0.90mg/kg, stratifying for patient age (>80 years). Outcomes evaluated include 90-day modified Rankin scale (mRS), all-cause mortality, and symptomatic ICH. Treatment effect was adjusted for baseline NIHSS, age, and time from symptom onset to puncture via mixed effects proportional odds and logistic regression models. RESULTS In patients >80 years (n=137), TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs. 4, adjusted common OR=2.70, 95% CI: 1.23-5.94) and reduced mortality (aOR=0.34, 95% CI: 0.13-0.91) versus 0.40 mg/kg. TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs. 4, acOR=2.28, 95% CI: 1.03-5.05) versus alteplase. No difference in 90-day mRS or mortality was detected between alteplase and TNK 0.40 mg/kg. Symptomatic ICH was observed in 4 patients treated with TNK 0.40 mg/kg, one patient treated with alteplase and zero patients treated with TNK 0.25 mg/kg. In patients ≤ 80 years, no differences in 90-day mRS, mortality, or symptomatic ICH was observed between TNK 0.25 mg/kg, alteplase, and TNK 0.40 mg/kg. CONCLUSIONS TNK 0.25 mg/kg was associated with improved 90-day mRS and lower mortality in patients greater than 80 years of age. No differences between the doses were observed in younger patients. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tenecteplase 0.25 mg/kg given before endovascular therapy in patients >80 years old with large vessel occlusion stroke is associated with better functional outcomes at 90 days and reduced mortality when compared to tenecteplase 0.40 mg/kg or alteplase 0.90 mg/kg. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT02388061, NCT03340493 https://www.clinicaltrials.gov/ct2/show/NCT02388061 https://www.clinicaltrials.gov/ct2/show/NCT03340493.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Vincent Thijs
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Melbourne Medical School, Department of Medicine and Neurology, The University of Melbourne and Western Health, Sunshine Hospital, St Albans Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Geoffrey Alan Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
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31
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Deb-Chatterji M, Pinho J, Flottmann F, Meyer L, Broocks G, Brekenfeld C, Reich A, Fiehler J, Gerloff C, Thomalla G. Health-related quality of life after thrombectomy in young-onset versus older stroke patients: a multicenter analysis. J Neurointerv Surg 2021; 14:1145-1150. [PMID: 34876497 DOI: 10.1136/neurintsurg-2021-017991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/06/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Information is lacking on self-reported health-related quality of life (HRQoL) as a complementary outcome measure in addition to the modified Rankin scale (mRS) in young patients with ischemic stroke after endovascular thrombectomy (EVT) compared with older patients. METHODS Data on consecutive patients with stroke who underwent thrombectomy (June 2015-2019) from a multicenter prospective registry (German Stroke Registry) were analyzed. HRQoL was measured by the European QoL-5 dimension questionnaire utility index (EQ-5D-I; higher values indicate better HRQoL) 3 months after stroke in patients aged ≤55 and >55 years. Multivariate regression analyses identified predictors of better HRQoL. RESULTS Of 4561 included patients, 526 (11.5%) were ≤55 years old. Young-onset patients had a better outcome assessed by mRS (mRS 0-2: 64.3% vs 31.8%, p<0.001) and EQ-5D-I (mean 0.639 vs 0.342, p<0.001). Young survivors after EVT had fewer complaints in the EQ-5D domains mobility (p<0.001), self-care (p<0.001), usual activities (p<0.001) and pain/discomfort (p=0.008), whereas no difference was observed in anxiety/depression (p=0.819). Adjusted regression analysis for 90-day mRS showed no difference in HRQoL between the two subgroups of patients. Lower age, National Institutes of Health Stroke Scale score and pre-stroke mRS, a higher Alberta Stroke Program Early CT Score, concomitant intravenous thrombolysis therapy and successful recanalization were associated with better HRQoL in both patient subgroups. CONCLUSIONS Young-onset stroke patients have a better HRQoL after EVT than older patients. Their higher HRQoL is mainly explained by less physical disability assessed by mRS. Depressive symptoms should be actively assessed and targeted in rehabilitation therapies of young-onset stroke patients to improve quality of life after stroke.
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Affiliation(s)
- Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - João Pinho
- Department of Neurology, RWTH Aachen University, Aachen, Nordrhein-Westfalen, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arno Reich
- Department of Neurology, RWTH Aachen University, Aachen, Nordrhein-Westfalen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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32
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Kauffmann J, Grün D, Yilmaz U, Wagenpfeil G, Faßbender K, Fousse M, Unger MM. Acute stroke treatment and outcome in the oldest old (90 years and older) at a tertiary care medical centre in Germany-a retrospective study showing safety and efficacy in this particular patient population. BMC Geriatr 2021; 21:611. [PMID: 34715796 PMCID: PMC8556881 DOI: 10.1186/s12877-021-02566-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background Stroke is among the most common causes of death and disability worldwide. Despite the relevance of stroke-related disease burden, which is constantly increasing due to the demographic change in industrialized countries with an ageing population and consecutively an increase in age-associated diseases, there is sparse evidence concerning acute stroke treatment and treatment-related outcome in the elderly patient group. This retrospective study aimed at analysing patient characteristics, therapy-related complications and functional outcome in stroke patients aged 90 years or older who underwent acute stroke treatment (i.e. intravenous thrombolysis, mechanical thrombectomy, or both). Methods We identified files of all inpatient stays at the Department of Neurology at Saarland University Medical Center (tertiary care level with a comprehensive stroke unit) between June 2011 and December 2018 and filtered for subjects aged 90 years or older at the time of admission. We reviewed patient files for demographic data, symptoms upon admission, (main) diagnoses, comorbidities, and administered therapies. For patients admitted due to acute stroke we reviewed files for therapy-related complications and functional outcome. We compared the modified Rankin scale (mRS) scores upon admission and at discharge for these patients. Results We identified 566 inpatient stays of subjects aged 90 years or older. Three hundred sixty-seven of the 566 patients (64.8%) were admitted and discharged due to symptoms indicative of stroke. Two hundred eleven patients received a diagnosis of ischaemic stroke. These 211 patients were analysed subsequently. Sixty-four patients qualified for acute stroke treatment (intravenous thrombolysis n = 22, mechanical thrombectomy n = 26, intravenous thrombolysis followed by mechanical thrombectomy n = 16) and showed a significant improvement in their functional status as measured by change in mRS score (admission vs. discharge, p 0.001) with 7 (10.9%) observed potentially therapy-related complications (relevant drop in haemoglobin n = 2, subarachnoidal haemorrhage n = 1, cerebral haemorrhage n = 3, extracranial bleeding n = 1). One intravenous thrombolysis was stopped because of an uncontrollable hypertensive crisis. Patients who did not qualify for these treatments (including those declining acute treatment) did not show a change of their functional status between admission and discharge (p 0.064). Conclusion Our data indicate that acute stroke treatment is effective and safe in the oldest old. Age alone is no criterion to withhold an acute intervention even in oldest old stroke patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02566-3.
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Affiliation(s)
- Jil Kauffmann
- Department of Neurology, Saarland University Medical Center, Kirrberger Str., 66421, Homburg, Germany
| | - Daniel Grün
- Department of Neurology, Saarland University Medical Center, Kirrberger Str., 66421, Homburg, Germany
| | - Umut Yilmaz
- Department of Neuroradiology, Saarland University Medical Center, Kirrberger Str., 66421, Homburg, Germany
| | - Gudrun Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Kirrberger Str., 66421, Homburg, Germany
| | - Klaus Faßbender
- Department of Neurology, Saarland University Medical Center, Kirrberger Str., 66421, Homburg, Germany
| | - Mathias Fousse
- Department of Neurology, Saarland University Medical Center, Kirrberger Str., 66421, Homburg, Germany
| | - Marcus M Unger
- Department of Neurology, Saarland University Medical Center, Kirrberger Str., 66421, Homburg, Germany.
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33
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Luijten SPR, Compagne KCJ, van Es ACGM, Roos YBWEM, Majoie CBLM, van Oostenbrugge RJ, van Zwam WH, Dippel DWJ, Wolters FJ, van der Lugt A, Bos D. Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial. Int J Stroke 2021; 17:17474930211054964. [PMID: 34711105 PMCID: PMC9483187 DOI: 10.1177/17474930211054964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Brain atrophy is suggested to impair the potential for functional recovery after acute ischemic stroke. We assessed whether the effect of endovascular treatment is modified by brain atrophy in patients with acute ischemic stroke due to large vessel occlusion. METHODS We used data from MR CLEAN, a multicenter trial including patients with acute ischemic stroke due to anterior circulation large vessel occlusion randomized to endovascular treatment plus medical care (intervention) versus medical care alone (control). We segmented total brain volume (TBV) and intracranial volume (ICV) on baseline non-contrast computed tomography (n = 410). Next, we determined the degree of atrophy as the proportion of brain volume in relation to head size (1 - TBV/ICV) × 100%, analyzed as continuous variable and in tertiles. The primary outcome was a shift towards better functional outcome on the modified Rankin Scale expressed as adjusted common odds ratio. Treatment effect modification was tested using an interaction term between brain atrophy (as continuous variable) and treatment allocation. RESULTS We found that brain atrophy significantly modified the effect of endovascular treatment on functional outcome (P for interaction = 0.04). Endovascular treatment led to larger shifts towards better functional outcome in the higher compared to the lower range of atrophy (adjusted common odds ratio, 1.86 [95% CI: 0.97-3.56] in the lowest tertile vs. 1.97 [95% CI: 1.03-3.74] in the middle tertile vs. 3.15 [95% CI: 1.59-6.24] in the highest tertile). CONCLUSION Benefit of endovascular treatment is larger in the higher compared to the lower range of atrophy, demonstrating that advanced atrophy should not be used as an argument to withhold endovascular treatment.
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Affiliation(s)
- Sven PR Luijten
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Kars CJ Compagne
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Adriaan CGM van Es
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Frank J Wolters
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Ruiz A, Longstreth WT, Tirschwell DL, Creutzfeldt CJ. What defines success following reperfusion after mechanical thrombectomy for older patients in the real world? J Neurol 2021; 269:2214-2218. [PMID: 34674008 DOI: 10.1007/s00415-021-10859-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/15/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Amber Ruiz
- Department of Neurology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - David L Tirschwell
- Department of Neurology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA.
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35
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Rudilosso S, Ríos J, Rodríguez A, Gomis M, Vera V, Gómez-Choco M, Renú A, Matos N, Llull L, Purroy F, Amaro S, Terceño M, Obach V, Serena J, Martí-Fàbregas J, Cardona P, Molina C, Rodríguez-Campello A, Cánovas D, Krupinski J, Ustrell X, Torres F, Román LS, Salvat-Plana M, Jiménez-Fàbrega FX, Palomeras E, Catena E, Colom C, Cocho D, Baiges J, Aragones JM, Diaz G, Costa X, Almendros MC, Rybyeba M, Barceló M, Carrión D, Lòpez MN, Sanjurjo E, de la Ossa NP, Urra X, Chamorro Á. Effectiveness of Thrombectomy in Stroke According to Baseline Prognostic Factors: Inverse Probability of Treatment Weighting Analysis of a Population-Based Registry. J Stroke 2021; 23:401-410. [PMID: 34649384 PMCID: PMC8521260 DOI: 10.5853/jos.2021.00962] [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: 03/14/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose In real-world practice, the benefit of mechanical thrombectomy (MT) is uncertain in stroke patients with very favorable or poor prognostic profiles at baseline. We studied the effectiveness of MT versus medical treatment stratifying by different baseline prognostic factors. Methods Retrospective analysis of 2,588 patients with an ischemic stroke due to large vessel occlusion nested in the population-based registry of stroke code activations in Catalonia from January 2017 to June 2019. The effect of MT on good functional outcome (modified Rankin Score ≤2) and survival at 3 months was studied using inverse probability of treatment weighting (IPTW) analysis in three pre-defined baseline prognostic groups: poor (if pre-stroke disability, age >85 years, National Institutes of Health Stroke Scale [NIHSS] >25, time from onset >6 hours, Alberta Stroke Program Early CT Score <6, proximal vertebrobasilar occlusion, supratherapeutic international normalized ratio >3), good (if NIHSS <6 or distal occlusion, in the absence of poor prognostic factors), or reference (not meeting other groups’ criteria).
Results Patients receiving MT (n=1,996, 77%) were younger, had less pre-stroke disability, and received systemic thrombolysis less frequently. These differences were balanced after the IPTW stratified by prognosis. MT was associated with good functional outcome in the reference (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0 to 4.4), and especially in the poor baseline prognostic stratum (OR, 3.9; 95% CI, 2.6 to 5.9), but not in the good prognostic stratum. MT was associated with survival only in the poor prognostic stratum (OR, 2.6; 95% CI, 2.0 to 3.3).
Conclusions Despite their worse overall outcomes, the impact of thrombectomy over medical management was more substantial in patients with poorer baseline prognostic factors than patients with good prognostic factors.
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Affiliation(s)
- Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain.,Clinical and Experimental Neuroscience: Cerebrovascular Diseases, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - José Ríos
- Medical Statistics Core Facility, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Hospital Clinic, Barcelona, Spain.,Biostatistics Unit, Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Alejandro Rodríguez
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Meritxell Gomis
- Stroke Unit, Department of Neuroscience, Germans Trias Hospital, Badalona, Spain
| | - Víctor Vera
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | - Arturo Renú
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain.,Clinical and Experimental Neuroscience: Cerebrovascular Diseases, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Núria Matos
- Department of Neurology, Althaia Foundation Hospital, Manresa, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain.,Clinical and Experimental Neuroscience: Cerebrovascular Diseases, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francisco Purroy
- Stroke Unit, Department of Neurology, University Hospital Arnau of Vilanova, Lleida, Spain
| | - Sergio Amaro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain.,Clinical and Experimental Neuroscience: Cerebrovascular Diseases, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Mikel Terceño
- Stroke Unit, Department of Neurology, Josep Trueta University Hospital, Girona, Spain
| | - Víctor Obach
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Joaquim Serena
- Stroke Unit, Department of Neurology, Josep Trueta University Hospital, Girona, Spain
| | - Joan Martí-Fàbregas
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau, Barcelona, Spain
| | - Pedro Cardona
- Stroke Unit, Department of Neurology, Bellvitge University Hospital, Barcelona, Spain
| | - Carlos Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - David Cánovas
- Department of Neurology, Parc Taulí Hospital, Sabadell, Spain
| | - Jerzy Krupinski
- Department of Neurology, Mutua de Terrassa University Hospital, Terrassa, Spain
| | - Xavier Ustrell
- Stroke Unit, Department of Neurology, Joan XXIII University Hospital, Terragona, Spain
| | - Ferran Torres
- Medical Statistics Core Facility, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Hospital Clinic, Barcelona, Spain.,Biostatistics Unit, Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Luis San Román
- Department of Radiology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Mercè Salvat-Plana
- Department of Health, Pla Director Malaltia Vascular Cerebral (Catalan Stroke Program), Barcelona, Spain
| | | | | | - Esther Catena
- Department of Neurology, Consorci Sanitari Garraf Hospital, Sant Pere de Ribes, Spain
| | - Carla Colom
- Department of Emergency, Hospital of Igualada, Igualada, Spain
| | - Dolores Cocho
- Department of Emergency, Hospital of Granollers, Granollers, Spain
| | - Juanjo Baiges
- Department of Emergency, Verge de la Cinta Hospital, Tortosa, Spain
| | | | - Gloria Diaz
- Department of Emergency, Hospital of Campdevànol, Campdevànol, Spain
| | - Xavier Costa
- Department of Emergency, Hospital of Figueres, Figueres, Spain
| | | | - Maria Rybyeba
- Department of Emergency, Hospital of Olot, Olot, Spain
| | - Miquel Barceló
- Department of Emergency, Cerdanya Hospital, Puigcerdá, Spain
| | - Dolors Carrión
- Department of Emergency, Hospital of Móra d'Ebre, Móra d'Ebre, Spain
| | | | | | - Natalia Pérez de la Ossa
- Stroke Unit, Department of Neuroscience, Germans Trias Hospital, Badalona, Spain.,Department of Health, Pla Director Malaltia Vascular Cerebral (Catalan Stroke Program), Barcelona, Spain
| | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain.,Clinical and Experimental Neuroscience: Cerebrovascular Diseases, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Ángel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain.,Clinical and Experimental Neuroscience: Cerebrovascular Diseases, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | -
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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37
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Pinho J, Küppers C, Nikoubashman O, Wiesmann M, Schulz JB, Reich A, Werner CJ. Frailty is an outcome predictor in patients with acute ischemic stroke receiving endovascular treatment. Age Ageing 2021; 50:1785-1791. [PMID: 34087930 DOI: 10.1093/ageing/afab092] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/14/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Frailty is a disorder of multiple physiological systems impairing the capacity of the organism to cope with insult or stress. It is associated with poor outcomes after acute illness. Our aim was to study the impact of frailty on the functional outcome of patients with acute ischemic stroke (AIS) submitted to endovascular stroke treatment (EST). METHODS We performed a retrospective study of patients with AIS of the anterior circulation submitted to EST between 2012 and 2017, based on a prospectively collected local registry of consecutive patients. The Hospital Frailty Risk Score (HFRS) at discharge was calculated for each patient. We compared groups of patients with and without favourable 3-month outcome after index AIS (modified Rankin Scale 0-2 and 3-6, respectively). A multivariable logistic regression model was used to identify variables independently associated with favourable 3-month outcome. Diagnostic test statistics were used to compare HFRS with other prognostic scores for AIS. RESULTS We included 489 patients with median age 75.6 years (interquartile range [IQR] = 65.3-82.3) and median NIHSS 15 (IQR = 11-19). About 29.7% presented a high frailty risk (HFRS >15 points). Patients with favourable 3-month outcome presented lower HFRS and lower prevalence of high frailty risk. High frailty risk was independently associated with decreased likelihood of favourable 3-month outcome (adjusted odds ratio = 0.48, 95% confidence interval = 0.26-0.89). Diagnostic performances of HFRS and other prognostic scores (THRIVE and PRE scores, SPAN-100 index) for outcome at 3-months were similar. DISCUSSION Frailty is an independent predictor of outcome in AIS patients submitted to EST.
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Affiliation(s)
- João Pinho
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Charlotte Küppers
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Jörg B Schulz
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen D-52074, Germany
| | - Arno Reich
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Cornelius J Werner
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
- Department of Neurology, Medical Faculty, Section Interdisciplinary Geriatrics, RWTH Aachen University, Aachen D-52074, Germany
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38
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Duloquin G, Graber M, Baptiste L, Mohr S, Garnier L, Ndiaye M, Blanc-Labarre C, Hervieu-Bègue M, Osseby GV, Giroud M, Béjot Y. [Management of ischemic stroke in the acute phase]. Rev Med Interne 2021; 43:286-292. [PMID: 34481684 DOI: 10.1016/j.revmed.2021.08.003] [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: 06/30/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Ischemic stroke accounts for 80% of overall stroke, and is one of the leading causes of death, disability and dementia in worldwide. Management of patients with acute ischemic stroke dramatically improved over time with the implementation of intensive care stroke units, the development of acute recanalization strategies, the optimization of the management of post-stroke complications, and the prevention of early stroke recurrence. The objective of this article is to provide a general overview of the current management of patients with acute ischemic stroke aiming at improving post-stroke outcome.
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Affiliation(s)
- G Duloquin
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Graber
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - L Baptiste
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - S Mohr
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - L Garnier
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Ndiaye
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - C Blanc-Labarre
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Hervieu-Bègue
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - G-V Osseby
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - M Giroud
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France
| | - Y Béjot
- EA7460, UBFC, registre dijonnais des AVC, service hospitalo-universitaire de neurologie, CHU de Dijon-Bourgogne, université de Bourgogne, Dijon, France.
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39
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Sudre J, Venditti L, Ancelet C, Chassin O, Sarov M, Smadja D, Chausson N, Lun F, Laine O, Duron E, Verny C, Spelle L, Rouquette A, Legris N, Denier C. Reperfusion therapy for acute ischemic stroke in older people: An observational real-life study. J Am Geriatr Soc 2021; 69:3167-3176. [PMID: 34374987 DOI: 10.1111/jgs.17394] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND While randomized clinical trials have shown the benefit of thrombolysis and endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS), we aimed to describe in a real-life study the differences between older (>80 years old) and younger patients treated for AIS. METHODS Thousand patients treated with thrombolysis and/or EVT were consecutively included in a prospective monocentric database (admitted from December 2015 to May 2019 in our comprehensive stroke center). Demographic data with detailed history, baseline physical examinations and treatments, laboratory and imaging data, prestroke functional status, and outcome 3 months after stroke were analyzed. RESULTS Older patients (n = 357) had more baseline comorbidities and lower levels of prestroke independence (modified Rankin scale ≤2; 67.2% vs. 96.1%) and more severe strokes (median National Institute of Health Stroke Score [NIHSS] 15 vs. 12; p < 0.001) than younger patients (n = 643). There was no difference in the reperfusion treatments used or treatment timelines. In older patients, good functional status at 3 months was less common (29.7% vs. 61.3%) and mortality was higher (37.1% vs. 11.4%) than in younger patients. Younger age was independently associated with better prognosis (odds ratio [OR] 0.37, 95% confidence interval [CI]: 0.20-0.67; p = 0.001) and lower mortality (OR 4.38, 95% CI: 2.11-9.09; p < 0.001). Among older adults, features associated with good outcome at 3 months were age (OR 0.89, 95% CI: 0.81-0.97; p = 0.01), initial NIHSS (OR 0.89, 95% CI: 0.83-0.94; p < 0.0001), and absence of severe leukoaraiosis, anticoagulant treatment, and symptomatic intracerebral hemorrhage following reperfusion therapy (respectively, OR 0.42, 95% CI: 0.19-0.93; p = 0.03; OR = 0.07, 95% CI: 0.01-0.70; p = 0.02; and OR = 0.07, 95% CI: 0.01-0.61; p = 0.02). CONCLUSION Although reperfusion therapy was less successful in older patients, these patients may benefit from acute recanalization despite their age. With an increasing older adult population, high-quality prospective studies are still required to better predict functional outcome and clarify the criteria that would allow better selection of appropriate treatment.
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Affiliation(s)
- Justine Sudre
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Laura Venditti
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Claire Ancelet
- Neuroradiology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Olivier Chassin
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Mariana Sarov
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Didier Smadja
- Department of Neurology, Centre Hospitalier Sud Francilien, Paris Saclay University, Corbeil-Essonnes, France
| | - Nicolas Chausson
- Department of Neurology, Centre Hospitalier Sud Francilien, Paris Saclay University, Corbeil-Essonnes, France
| | - François Lun
- Department of Neurology, Groupe Hospitalier Nord Essonne, Orsay, France
| | - Olga Laine
- Hôpital Gériatrique Les Magnolias, Ballainvilliers, France
| | - Emmanuelle Duron
- Geriatric Center, Paul Brousse Hôpitaux Universitaires Paris Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Christiane Verny
- Geriatric Center, Bicêtre Hôpitaux Universitaires Paris Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Laurent Spelle
- Neuroradiology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Alexandra Rouquette
- Public Health and Epidemiology Department, Assistance Publique-Hôpitaux de Paris, Bicêtre Hôpitaux Universitaires Paris Sud, Université Paris Saclay, CESP, Inserm, Le Kremlin Bicêtre, France
| | - Nicolas Legris
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Christian Denier
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
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Bres-Bullrich M, Fridman S, Sposato LA. Relative Effect of Stroke Severity and Age on Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke. Stroke 2021; 52:2846-2848. [PMID: 34233461 DOI: 10.1161/strokeaha.121.034946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maria Bres-Bullrich
- Department of Clinical Neurological Sciences (M.B.-B., S.F., L.A.S.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Sebastian Fridman
- Department of Clinical Neurological Sciences (M.B.-B., S.F., L.A.S.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences (M.B.-B., S.F., L.A.S.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics (L.A.S.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Department of Anatomy and Cell Biology (L.A.S.), Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Heart & Brain Laboratory (L.A.S.), Western University, London, ON, Canada.,Robarts Research Institute (L.A.S.), Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada (L.A.S.)
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41
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[Thrombectomy in clinical practice-What do we learn from registry studies?]. DER NERVENARZT 2021; 92:744-751. [PMID: 33942134 PMCID: PMC8092363 DOI: 10.1007/s00115-021-01122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 10/28/2022]
Abstract
BACKGROUND In 2015, randomized controlled trials (RCT) provided high-level evidence for the efficacy of endovascular thrombectomy in selected patients with acute ischemic stroke due to large vessel occlusion of the anterior circulation. Ever since, thrombectomy is strongly recommended for these patients and has been broadly implemented in clinical practice. OBJECTIVE To determine whether registry studies depicting real-life data provide additional information beyond RCTs. MATERIAL AND METHODS Literature review of RCTs and registry studies related to thrombectomy. RESULTS Data from registry studies on thrombectomy are important to 1. evaluate whether RCT results can be directly transferred into clinical practice, 2. comparatively describe the efficacy of thrombectomy in patient groups underrepresented in RCTs, such as older patients, 3. compare device performances and assess technical developments, and 4. determine how treatment processes and outcomes change over time. CONCLUSION Beyond RCTs, registry studies are imperative for the continuous analysis and improvement of treatment processes and outcomes as well as technical devices in daily clinical practice.
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42
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Predictors of Outcome After Mechanical Thrombectomy in Stroke Patients Aged ≥85 Years. Can J Neurol Sci 2021; 49:49-54. [PMID: 33685540 DOI: 10.1017/cjn.2021.37] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The effectiveness of mechanical thrombectomy (MT) in elderly stroke patients remains debated. We aimed to describe outcomes and their predictors in a cohort of patients aged ≥ 85 years treated with MT. METHODS Data from consecutive patients aged ≥ 85 years undergoing MT at two stroke centers between January 2016 and November 2019 were reviewed. Admission National Institutes of Health Stroke Scale (NIHSS), pre-stroke, and 3-month modified Rankin scale (mRS) were collected. Successful recanalization was defined as modified thrombolysis in cerebral ischemia score ≥ 2b. Good outcome was defined as mRS 0-3 or equal to pre-stroke mRS at 3 months. RESULTS Of 151 included patients, successful recanalization was achieved in 74.2%. At 3 months, 44.7% of patients had a good outcome and 39% had died. Any intracranial hemorrhage (ICH) and symptomatic ICH occurred in 20.3% and 3.6%, respectively. Logistic regression analysis identified lower pre-stroke mRS score (adjusted odds ratio [aOR], 0.52; 95% CI, 0.36-0.76), lower admission NIHSS score (aOR, 0.90; 95% CI, 0.83-0.97), successful recanalization (aOR, 3.65; 95% CI, 1.32-10.09), and absence of ICH on follow-up imaging (aOR, 0.42; 95% CI, 0.08-0.75), to be independent predictors of good outcome. Patients with successful recanalization had a higher proportion of good outcome (45.3% vs 34.3%, p = 0.013) and lower mortality at 3 months (35.8% vs 48.6%, p = 0.006) compared to patients with unsuccessful recanalization. CONCLUSIONS Among patients aged ≥ 85 years, successful recanalization with MT is relatively common and associated with better 3-month outcome and lower mortality than failed recanalization. Attempting to achieve recanalization in elderly patients using MT appears reasonable.
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43
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Suzuki S, Wadi L, Moores L, Yuki I, Kim J, Xu J, Paganini-Hill A, Fisher M. Stroke Preventability in Large Vessel Occlusion Treated With Mechanical Thrombectomy. Front Neurol 2021; 12:608084. [PMID: 33763011 PMCID: PMC7982657 DOI: 10.3389/fneur.2021.608084] [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: 09/18/2020] [Accepted: 01/28/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: The preventability of strokes treated by mechanical thrombectomy is unknown. The purpose of this study was to analyze stroke preventability for patients treated with mechanical thrombectomy for large vessel occlusion. Methods: We conducted retrospective analyses of 300 patients (mean ± SE age 69 ± 0.9 years, range 18–97 years; 53% male) treated with mechanical thrombectomy for large vessel occlusion from January 2008 to March 2019. We collected data including demographics, NIH Stroke Scale (NIHSS) at onset, and (beginning in 2015) classified 90-day outcome by modified Rankin Scale (mRS). Patients were evaluated using a Stroke Preventability Score (SPS, 0 to 10 points) based on how well patients had been treated given their hypertension, hyperlipidemia, atrial fibrillation, and prior stroke history. We examined the relationship of SPS with NIHSS at stroke onset and with mRS outcome at 90 days. Results: SPS was calculated for 272 of the 300 patients, with mean ± SE of 2.1 ± 0.1 (range 0–8); 89 (33%) had no preventability (score 0), 120 (44%) had low preventability (score 1–3), and 63 (23%) had high preventability (score 4 or higher). SPS was significantly correlated with age (r = 0.32, p < 0.0001), while NIHSS (n = 267) was significantly higher (p = 0.03) for patients with high stroke preventability vs. low/no preventability [18.8 ± 0.92 (n = 62) vs. 16.5 ± 0.51 (n = 205)]. Among 118 patients with mRS, outcome was significantly worse (p = 0.04) in patients with high stroke preventability vs. low/no preventability [4.7 ± 0.29 (n = 28) vs. 3.8 ± 0.21 (n = 90)]. The vast majority of patients with high stroke preventability had inadequately treated atrial fibrillation (85%, 53/62). Conclusions: Nearly one quarter of stroke patients undergoing mechanical thrombectomy had highly preventable strokes. While stroke preventability showed some relationship to stroke severity at onset and outcome after treatment, preventability had the strongest association with age. These findings emphasize the need for improved stroke prevention in the elderly.
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Affiliation(s)
- Shuichi Suzuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Lara Wadi
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Lisa Moores
- UC Irvine Medical Center, Orange, CA, United States
| | - Ichiro Yuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Jeein Kim
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Jordan Xu
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Annlia Paganini-Hill
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Mark Fisher
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
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Sposato LA, Lorenzano S. Real-world data for mechanical thrombectomy in the elderly population. Neurology 2020; 95:57-58. [DOI: 10.1212/wnl.0000000000009766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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