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Wang T, Jin X, Yang P, Li S, Zhang Q, Shao C, Lu J, Jin X, Chen L. A clinical and computed tomography-based nomogram to predict the outcome in patients with anterior circulation large vessel occlusion after endovascular mechanical thrombectomy. Jpn J Radiol 2024; 42:973-982. [PMID: 38700623 DOI: 10.1007/s11604-024-01583-7] [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: 04/02/2024] [Accepted: 04/23/2024] [Indexed: 08/31/2024]
Abstract
PURPOSE To explore the positive predictors of the clinical outcome in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion (ACLVO) after endovascular mechanical thrombectomy (EMT) at a 90-day follow-up, and to establish a nomogram model to predict the clinical outcome. MATERIALS AND METHODS AIS patients with ACLVO detected by multimodal Computed Tomography imaging who underwent EMT were collected. Patients were divided into the favorable and the unfavorable groups according to the 90-day modified Rankin Scale (mRS) score. Univariate and multivariate analyses were performed to investigate predictors of the favorable outcome (mRS of 0-2). A nomogram model for predicting the clinical outcome after EMT was drawn, and the receiver operating characteristic (ROC) curve was used to evaluate its predictive value. RESULTS Totally 105 patients including 65 patients in the favorable group and 40 in the unfavorable group were enrolled. Multivariate logistic regression analysis showed that admission National Institute of Health Stroke scale (NIHSS) score [0.858 (95% CI 0.778-0.947)], ACLVO at M2 [20.023 (95% CI 2.204-181.907)] and infarct core (IC) volume [0.943 (95% CI 0.917-0.969)] was positively correlated with favorable outcome. The accuracy of the nomogram model in predicting the outcome was 0.923 (95% CI 0.870-0.976), with a cutoff value of 119.6 points. The area under the ROC curve was 0.848 (95% CI 0.780-0.917; sensitivity, 79.7%; specificity, 90.0%). CONCLUSION A low Admission NIHSS score, ACLVO at M2, and a small IC volume were positive predictors for favorable outcome. The nomogram model may well predict the outcome in AIS patients with ACLVO after EMT.
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Affiliation(s)
- Tiegong Wang
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Xiangyu Jin
- Hainan College of Economics and Business, Haikou, 571127, Hainan, China
| | - Panpan Yang
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Shuai Li
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Qianwen Zhang
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Chengwei Shao
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China
| | - Xianglan Jin
- Department of Intensive Care Unit, Shanghai Tenth People's Hospital, Tongji University, No. 301 Yanchang Middle Road, Shanghai, 200072, China.
| | - Luguang Chen
- Department of Radiology, Changhai Hospital, Naval Medical University, No. 168 Changhai Road, Shanghai, 200433, China.
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Rodriguez MP, Taleb S, Lee JJH, Liebeskind DS, Saver JL. AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS: new imaging scales to assess territorial and total cerebral hemispheric ischemic injury. Front Neurol 2024; 15:1397120. [PMID: 39022729 PMCID: PMC11252022 DOI: 10.3389/fneur.2024.1397120] [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: 03/06/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Background The extent of ischemic injury in acute stroke is assessed in clinical practice using the Acute Stroke Prognosis Early CT Score (ASPECTS) rating system. However, current ASPECTS semi-quantitative topographic scales assess only the middle cerebral artery (MCA) (original ASPECTS) and posterior cerebral (PC-ASPECTS) territories. For treatment decision-making in patients with anterior cerebral artery (ACA) occlusions and internal carotid artery (ICA) occlusions with large ischemic cores, measures of all hemispheric regions are desirable. Methods In this cohort study, anatomic rating systems were developed for the anterior cerebral (AC-ASPECTS, 3 points) and anterior choroidal artery (ACh-ASPECTS, 1 point) territories. In addition, a total supratentorial hemisphere (H-ASPECTS, 16 points) score was calculated as the sum of the MCA ASPECTS (10 regions), supratentorial PC-ASPECTS (2 regions), AC-ASPECTS (3 regions), and ACh-ASPECTS (1 region). Three raters applied these scales to initial and 24 h CT and MR images in consecutive patients with ischemic stroke (IS) due to ICA, M1-MCA, and ACA occlusions. Results Imaging ratings were obtained for 96 scans in 50 consecutive patients with age 74.8 (±14.0), 60% female, NIHSS 15.5 (9.25-20), and occlusion locations ICA 34%; M1-MCA 58%; and ACA 8%. Treatments included endovascular thrombectomy +/- thrombolysis in 72%, thrombolysis alone in 8%, and hemicraniectomy in 4%. Among experienced clinicians, inter-rater reliability for AC-, ACh-, and H-ASPECTS scores was substantial (kappa values 0.61-0.80). AC-ASPECTS abnormality was present in 14% of patients, and ACh-ASPECTS abnormality in 2%. Among patients with ACA and ICA occlusions, H-ASPECTS scores compared with original ASPECTS scores were more strongly associated with disability level at discharge, ambulatory status at discharge, discharge destination, and combined inpatient mortality and hospice discharge. Conclusion AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS expand the scope of acute IS imaging scores and increase correlation with functional outcomes. This additional information may enhance prognostication and decision-making, including endovascular thrombectomy and hemicraniectomy.
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Affiliation(s)
| | - Shayandokht Taleb
- Department of Neurology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jenny Ji-hyun Lee
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - David S. Liebeskind
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Sablić S, Dolić K, Budimir Mršić D, Čičmir-Vestić M, Matana A, Lovrić Kojundžić S, Marinović Guić M. Communicating Arteries and Leptomeningeal Collaterals: A Synergistic but Independent Effect on Patient Outcomes after Stroke. Neurol Int 2024; 16:620-630. [PMID: 38921950 PMCID: PMC11206870 DOI: 10.3390/neurolint16030046] [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: 04/25/2024] [Revised: 05/29/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
The collateral system is a compensatory mechanism activated in the acute phase of an ischemic stroke. It increases brain perfusion to the hypoperfused area. Arteries of the Willis' circle supply antegrade blood flow, while pial (leptomeningeal) arteries direct blood via retrograde flow. The aim of our retrospective study was to investigate the relationship between both collateral systems, computed tomography perfusion (CTP) values, and functional outcomes in acute stroke patients. Overall, 158 patients with anterior circulation stroke who underwent mechanical thrombectomy were included in the study. We analyzed the presence of communicating arteries and leptomeningeal arteries on computed tomography angiography. Patients were divided into three groups according to their collateral status. The main outcomes were the rate of functional independence 3 months after stroke (modified Rankin scale score, mRS) and mortality rate. Our study suggests that the collateral status, as indicated by the three groups (unfavorable, intermediate, and favorable), is linked to CT perfusion parameters, potential recuperation ratio, and stroke outcomes. Patients with favorable collateral status exhibited smaller core infarct and penumbra volumes, higher mismatch ratios, better potential for recuperation, and improved functional outcomes compared to patients with unfavorable or intermediate collateral status.
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Affiliation(s)
- Sara Sablić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
| | - Krešimir Dolić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
- School of Medicine, University of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
| | - Danijela Budimir Mršić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
- School of Medicine, University of Split, 21000 Split, Croatia
| | - Mate Čičmir-Vestić
- Department of Neurology, University Hospital of Split, 21000 Split, Croatia;
| | - Antonela Matana
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
| | - Sanja Lovrić Kojundžić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
- School of Medicine, University of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
| | - Maja Marinović Guić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
- School of Medicine, University of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
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Shen H, Huasen BB, Killingsworth MC, Bhaskar SMM. Introducing the Futile Recanalization Prediction Score (FRPS): A Novel Approach to Predict and Mitigate Ineffective Recanalization after Endovascular Treatment of Acute Ischemic Stroke. Neurol Int 2024; 16:605-619. [PMID: 38921949 PMCID: PMC11206671 DOI: 10.3390/neurolint16030045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024] Open
Abstract
Objective: This study aims to develop and validate the Futile Recanalization Prediction Score (FRPS), a novel tool designed to predict the severity risk of FR and aid in pre- and post-EVT risk assessments. Methods: The FRPS was developed using a rigorous process involving the selection of predictor variables based on clinical relevance and potential impact. Initial equations were derived from previous meta-analyses and refined using various statistical techniques. We employed machine learning algorithms, specifically random forest regression, to capture nonlinear relationships and enhance model performance. Cross-validation with five folds was used to assess generalizability and model fit. Results: The final FRPS model included variables such as age, sex, atrial fibrillation (AF), hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, cognitive impairment, pre-stroke modified Rankin Scale (mRS), systolic blood pressure (SBP), onset-to-puncture time, sICH, and NIHSS score. The random forest model achieved a mean R-squared value of approximately 0.992. Severity ranges for FRPS scores were defined as mild (FRPS < 66), moderate (FRPS 66-80), and severe (FRPS > 80). Conclusions: The FRPS provides valuable insights for treatment planning and patient management by predicting the severity risk of FR. This tool may improve the identification of candidates most likely to benefit from EVT and enhance prognostic accuracy post-EVT. Further clinical validation in diverse settings is warranted to assess its effectiveness and reliability.
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Affiliation(s)
- Helen Shen
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
| | - Bella B. Huasen
- Department of Interventional Neuroradiology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston PR2 9HT, UK
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH16 4UX, UK
| | - Murray C. Killingsworth
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
- Ingham Institute for Applied Medical Research, Cell-Based Disease Intervention Group, Clinical Sciences Stream, Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Correlative Microscopy Facility, Ingham Institute for Applied Medical Research and Western Sydney University, Liverpool, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
- Ingham Institute for Applied Medical Research, Cell-Based Disease Intervention Group, Clinical Sciences Stream, Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South West Sydney Local Health District, Liverpool, NSW 2170, Australia
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Patel J, Bhaskar SMM. Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care. J Cardiovasc Dev Dis 2023; 10:458. [PMID: 37998516 PMCID: PMC10672610 DOI: 10.3390/jcdd10110458] [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: 10/03/2023] [Revised: 10/25/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023] Open
Abstract
Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab, Sydney 2150, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney 2170, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney 2150, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South Western Sydney Local Health District (SWSLHD), Sydney 2170, Australia
- Department of Neurology, National Cerebral and Cardiovascular Center (NCVC), Suita 564-8565, Osaka, Japan
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Faizy TD, Winkelmeier L, Mlynash M, Broocks G, Heitkamp C, Thaler C, van Horn N, Seners P, Kniep H, Stracke P, Zelenak K, Lansberg MG, Albers GW, Wintermark M, Fiehler J, Heit JJ. Brain edema growth after thrombectomy is associated with comprehensive collateral blood flow. J Neurointerv Surg 2023:jnis-2023-020921. [PMID: 37918909 DOI: 10.1136/jnis-2023-020921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/13/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND We determined whether a comprehensive assessment of cerebral collateral blood flow is associated with ischemic lesion edema growth in patients successfully treated by thrombectomy. METHODS This was a multicenter retrospective study of ischemic stroke patients who underwent thrombectomy treatment of large vessel occlusions. Collateral status was determined using the cerebral collateral cascade (CCC) model, which comprises three components: arterial collaterals (Tan Scale) and venous outflow profiles (Cortical Vein Opacification Score) on CT angiography, and tissue-level collaterals (hypoperfusion intensity ratio) on CT perfusion. Quantitative ischemic lesion net water uptake (NWU) was used to determine edema growth between admission and follow-up non-contrast head CT (ΔNWU). Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow), and CCCmixed (remainder of patients). Primary outcome was ischemic lesion edema growth (ΔNWU). Multivariable regression models were used to assess the primary and secondary outcomes. RESULTS 538 patients were included. 157 patients had CCC+, 274 patients CCCmixed, and 107 patients CCC- profiles. Multivariable regression analysis showed that compared with patients with CCC+ profiles, CCC- (β 1.99, 95% CI 0.68 to 3.30, P=0.003) and CCC mixed (β 1.65, 95% CI 0.75 to 2.56, P<0.001) profiles were associated with greater ischemic lesion edema growth (ΔNWU) after successful thrombectomy treatment. ΔNWU (OR 0.74, 95% CI 0.68 to 0.8, P<0.001) and CCC+ (OR 13.39, 95% CI 4.88 to 36.76, P<0.001) were independently associated with functional independence. CONCLUSION A comprehensive assessment of cerebral collaterals using the CCC model is strongly associated with edema growth and functional independence in acute stroke patients successfully treated by endovascular thrombectomy.
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Affiliation(s)
- Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mlynash
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Stracke
- Section of Interventional Neuroradiology, University Hospital Munster, Munster, Germany
| | - Kamil Zelenak
- Clinic of Radiology, Comenius University in Bratislava Jessenius Faculty of Medicine in Martin, Martin, Slovakia
- Clinic of Radiology, University Hospital Martin, Martin, Slovakia
| | - Maarten G Lansberg
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gregory W Albers
- Stanford Stroke Center, Stanford Medicine, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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Shen H, Killingsworth MC, Bhaskar SMM. Comprehensive Meta-Analysis of Futile Recanalization in Acute Ischemic Stroke Patients Undergoing Endovascular Thrombectomy: Prevalence, Factors, and Clinical Outcomes. Life (Basel) 2023; 13:1965. [PMID: 37895347 PMCID: PMC10608522 DOI: 10.3390/life13101965] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/12/2023] [Accepted: 09/24/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Futile recanalization (FR) continues to raise concern despite the success of endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). Understanding the prevalence of FR and identifying associated factors are crucial for refining patient prognoses and optimizing management strategies. OBJECTIVES This study aims to comprehensively assess the pooled prevalence of FR, explore the diverse factors connected with FR, and establish the association of FR with long-term clinical outcomes among AIS patients undergoing EVT. MATERIALS AND METHODS Incorporating studies focusing on FR following EVT in AIS patients, we conducted a random-effect meta-analysis to assess the pooled prevalence and its association with various clinical and imaging risk factors linked to FR. Summary estimates were compiled and study heterogeneity was explored. RESULTS Our comprehensive meta-analysis, involving 11,700 AIS patients undergoing EVT, revealed a significant pooled prevalence of FR at 51%, with a range of 48% to 54% (Effect Size [ES]: 51%; 95% Confidence Interval [CI]: 48-54%; z = 47.66; p < 0.001). Numerous clinical factors demonstrated robust correlations with FR, including atrial fibrillation (Odds Ratio [OR]: 1.39, 95% CI 1.22 1.59; p < 0.001), hypertension (OR 1.65, 95% CI 1.41 1.92; p < 0.001), diabetes mellitus (OR 1.71, 95% CI 1.47 1.99; p < 0.001), previous stroke or transient ischemic attack (OR 1.298, 95% CI 1.06 1.59; p = 0.012), prior anticoagulant usage (OR 1.33, 95% CI 1.08 1.63; p = 0.007), cardioembolic strokes (OR 1.34, 95% CI 1.10 1.63; p = 0.003), and general anesthesia (OR 1.53, 95% CI 1.35 1.74; p < 0.001). Conversely, FR exhibited reduced likelihoods of smoking (OR 0.66, 95% CI 0.57 0.77; p < 0.001), good collaterals (OR 0.33, 95% CI 0.23 0.49; p < 0.001), male sex (OR 0.87, 95% CI 0.77 0.97; p = 0.016), and intravenous thrombolysis (IVT) (OR 0.75, 95% CI 0.66 0.86; p < 0.001). FR was strongly associated with increasing age (standardized mean difference [SMD] 0.49, 95% CI 0.42 0.56; p < 0.0001), baseline systolic blood pressure (SMD 0.20, 95% CI 0.13 0.27; p < 0.001), baseline National Institute of Health Stroke Severity Score (SMD 0.75, 95% CI: 0.65 0.86; p < 0.001), onset-to-treatment time (SMD 0.217, 95% CI 0.13 0.30; p < 0.001), onset-to-recanalization time (SMD 0.38, 95% CI 0.19; 0.57; p < 0.001), and baseline blood glucose (SMD 0.31, 95% CI 0.22 0.41; p < 0.001), while displaying a negative association with reduced baseline Alberta Stroke Program Early CT Score (ASPECTS) (SMD -0.37, 95% CI -0.46 -0.27; p < 0.001). Regarding clinical outcomes, FR was significantly associated with increased odds of symptomatic intracranial hemorrhages (OR 7.37, 95% CI 4.89 11.12; p < 0.001), hemorrhagic transformations (OR 2.98, 95% CI 2.37 3.75; p < 0.001), and 90-day mortality (OR 19.24, 95% CI 1.57 235.18; p = 0.021). CONCLUSIONS The substantial prevalence of FR, standing at approximately 51%, warrants clinical consideration. These findings underscore the complexity of FR in AIS patients and highlight the importance of tailoring management strategies based on individual risk factors and clinical profiles.
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Affiliation(s)
- Helen Shen
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2052, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
| | - Murray C. Killingsworth
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2052, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Cell-Based Disease Intervention Research Group, Ingham Institute for Applied Medical Research and Liverpool Hospital, Liverpool, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
- Department of Neurology, National Cerebral and Cardiovascular Center (NCVC), Suita 564-8565, Osaka, Japan
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Patel J, Bhaskar SMM. Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes-A Comprehensive Systematic Review and Meta-Analysis. Neurol Int 2023; 15:1014-1043. [PMID: 37755356 PMCID: PMC10537209 DOI: 10.3390/neurolint15030065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
Atrial fibrillation (AF) significantly contributes to acute ischaemic stroke (AIS), yet its precise influence on clinical outcomes post-intravenous thrombolysis (IVT) and post-endovascular thrombectomy (EVT) has remained elusive. Furthermore, the overall prevalence of AF in AIS patients undergoing reperfusion therapy has not been clearly determined. Employing random-effects meta-analyses, this research aimed to estimate the pooled prevalence of AF among AIS patients undergoing reperfusion therapy, while also examining the association between AF and clinical outcomes such as functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. Studies comparing AF and non-AF patient groups undergoing reperfusion therapy were identified and included following an extensive database search. Forty-nine studies (n = 66,887) were included. Among IVT patients, the prevalence of AF was 31% (Effect Size [ES] 0.31 [95%CI 0.28-0.35], p < 0.01), while in EVT patients, it reached 42% (ES 0.42 [95%CI 0.38-0.46], p < 0.01), and in bridging therapy (BT) patients, it stood at 36% (ES 0.36 [95%CI 0.28-0.43], p < 0.01). AF was associated with significantly lower odds of favourable 90-day functional outcomes post IVT (Odds Ratio [OR] 0.512 [95%CI 0.376-0.696], p < 0.001), but not post EVT (OR 0.826 [95%CI 0.651-1.049], p = 0.117). Our comprehensive meta-analysis highlights the varying prevalence of AF among different reperfusion therapies and its differential impact on patient outcomes. The highest pooled prevalence of AF was observed in EVT patients, followed by BT and IVT patients. Interestingly, our analysis revealed that AF was significantly associated with poorer clinical outcomes following IVT. Such an association was not observed following EVT.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- South Western Sydney Clinical Campuses, University of New South Wales (UNSW) Medicine and Health, UNSW Sydney, Sydney, NSW 2170, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
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Zaidat OO, Ikeme S, Sheth SA, Yoshimura S, Yang XG, Brinjikji W, Kallmes DF, Brouwer P, Pederson J, Tarchand R, Steffenson A, Kallmes KM, Touchette J, Andersson T. MASTRO I: Meta-Analysis and Systematic Review of thrombectomy stent retriever outcomes: comparing functional, safety and recanalization outcomes between EmboTrap, Solitaire and Trevo in acute ischemic stroke. J Comp Eff Res 2023; 12:e230001. [PMID: 37039285 PMCID: PMC10402757 DOI: 10.57264/cer-2023-0001] [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: 01/03/2023] [Accepted: 03/02/2023] [Indexed: 04/12/2023] Open
Abstract
Aim: Stent-retriever (SR) thrombectomy has demonstrated superior outcomes in patients with acute ischemic stroke compared with medical management alone, but differences among SRs remain unexplored. We conducted a Systematic Review/Meta-Analysis to compare outcomes between three SRs: EmboTrap®, Solitaire™, and Trevo®. Methods: We conducted a PRISMA-compliant Systematic Review among English-language studies published after 2014 in PubMed/MEDLINE that reported SRs in ≥25 patients. Functional and safety outcomes included 90-day modified Rankin scale (mRS 0-2), mortality, symptomatic intracranial hemorrhage (sICH), and embolization to new territory (ENT). Recanalization outcomes included modified thrombolysis in cerebral infarction (mTICI) and first-pass recanalization (FPR). We used a random effects Meta-Analysis to compare outcomes; subgroup and outlier-influencer analysis were performed to explore heterogeneity. Results: Fifty-one articles comprising 9,804 patients were included. EmboTrap had statistically significantly higher rates of mRS 0-2 (57.4%) compared with Trevo (50.0%, p = 0.013) and Solitaire (45.3%, p < 0.001). Compared with Solitaire (20.4%), EmboTrap (11.2%, p < 0.001) and Trevo (14.5%, p = 0.018) had statistically significantly lower mortality. Compared with Solitaire (7.7%), EmboTrap (3.9%, p = 0.028) and Trevo (4.6%, p = 0.049) had statistically significantly lower rates of sICH. There were no significant differences in ENT rates across all three devices (6.0% for EmboTrap, 5.3% for Trevo, and 7.7% for Solitaire, p = 0.518). EmboTrap had numerically higher rates of recanalization; however, no statistically significant differences were found. Conclusion: The results of our Systematic Review/Meta-Analysis suggest that EmboTrap may be associated with significantly improved functional outcomes compared with Solitaire and Trevo. EmboTrap and Trevo may be associated with significantly lower rates of sICH and mortality compared with Solitaire. No significant differences in recanalization and ENT rates were found. These conclusions are tempered by limitations of the analysis including variations in thrombectomy techniques in the field, highlighting the need for multi-arm RCT studies comparing different SR devices to confirm our findings.
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Affiliation(s)
| | - Shelly Ikeme
- Cardiovascular & Specialty Solutions Group, CERENOVUS, Irvine, CA 92618, USA
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX 77030, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Hyogo, 663-8131, Japan
| | - Xin-guang Yang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, 510123, China
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN 55902, USA
| | - Patrick Brouwer
- Cardiovascular & Specialty Solutions Group, CERENOVUS, Irvine, CA 92618, USA
| | | | | | | | - Kevin M Kallmes
- Superior Medical Experts, St. Paul, MN 55117, USA
- Nested Knowledge, Inc., St. Paul, MN 55117, USA
| | | | - Tommy Andersson
- Medical Imaging, AZ Groeninge, 8500, Kortrijk, Belgium
- Neuroradiology, Karolinska University Hospital & Clinical Neuroscience Karolinska Institute, 171 77, Stockholm, Sweden
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10
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Meinel TR, Lerch C, Fischer U, Beyeler M, Mujanovic A, Kurmann C, Siepen B, Scutelnic A, Müller M, Goeldlin M, Belachew NF, Dobrocky T, Gralla J, Seiffge D, Jung S, Arnold M, Wiest R, Meier R, Kaesmacher J. Multivariable Prediction Model for Futile Recanalization Therapies in Patients With Acute Ischemic Stroke. Neurology 2022; 99:e1009-e1018. [PMID: 35803722 PMCID: PMC9519255 DOI: 10.1212/wnl.0000000000200815] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/19/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Very poor outcome despite IV thrombolysis (IVT) and mechanical thrombectomy (MT) occurs in approximately 1 of 4 patients with ischemic stroke and is associated with a high logistic and economic burden. We aimed to develop and validate a multivariable prognostic model to identify futile recanalization therapies (FRTs) in patients undergoing those therapies. METHODS Patients from a prospectively collected observational registry of a single academic stroke center treated with MT and/or IVT were included. The data set was split into a training (N = 1,808, 80%) and internal validation (N = 453, 20%) cohort. We used gradient boosted decision tree machine learning models after k-nearest neighbor imputation of 32 variables available at admission to predict FRT defined as modified Rankin scale 5-6 at 3 months. We report feature importance, ability for discrimination, calibration, and decision curve analysis. RESULTS A total of 2,261 patients with a median (interquartile range) age of 75 years (64-83 years), 46% female, median NIH Stroke Scale 9 (4-17), 34% IVT alone, 41% MT alone, and 25% bridging were included. Overall, 539 (24%) had FRT, more often in MT alone (34%) as compared with IVT alone (11%). Feature importance identified clinical variables (stroke severity, age, active cancer, prestroke disability), laboratory values (glucose, C-reactive protein, creatinine), imaging biomarkers (white matter hyperintensities), and onset-to-admission time as the most important predictors. The final model was discriminatory for predicting 3-month FRT (area under the curve 0.87, 95% CI 0.87-0.88) and had good calibration (Brier 0.12, 0.11-0.12). Overall performance was moderate (F1-score 0.63 ± 0.004), and decision curve analyses suggested higher mean net benefit at lower thresholds of treatment (up to 0.8). CONCLUSIONS This FRT prediction model can help inform shared decision making and identify the most relevant features in the emergency setting. Although it might be particularly useful in low resource healthcare settings, incorporation of further multifaceted variables is necessary to further increase the predictive performance.
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Affiliation(s)
- Thomas Raphael Meinel
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland.
| | - Christine Lerch
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Morin Beyeler
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Adnan Mujanovic
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Christoph Kurmann
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Bernhard Siepen
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Adrian Scutelnic
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Madlaine Müller
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Martina Goeldlin
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Nebiyat Filate Belachew
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Tomas Dobrocky
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Jan Gralla
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - David Seiffge
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Simon Jung
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Marcel Arnold
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Roland Wiest
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Raphael Meier
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Johannes Kaesmacher
- From the Department of Neurology (T.M., C.L., M.B., B.S., A.S., M.M., M.G., D.S., S.J., M.A.), University Hospital Bern, Inselspital, University of Bern; Department of Neurology and Stroke Center (U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (A.M., C.K., N.F.B., T.D., J.G., R.W., R.M., J.K.), Support Center for Advanced Neuroimaging (R.W., R.M., J.K.), and Department of Diagnostic, Paediatric and Interventional Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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11
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Wu T, Shi Z, Chen B, Geng Y, Pan J. TCD hemodynamics findings in the subacute phase of anterior circulation stroke patients treated with mechanical thrombectomy. Open Med (Wars) 2022; 17:606-613. [PMID: 35434377 PMCID: PMC8961283 DOI: 10.1515/med-2022-0464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/03/2022] Open
Abstract
Despite mechanical thrombectomy, the prognosis for many patients with anterior circulation ischemic stroke (ACIS) remains poor. This retrospective study reports consecutive mechanical thrombectomy procedures for ACIS at our hospital over 4 years. Hemodynamics were explored using transcranial Doppler ultrasound. The functional outcome was assessed using the modified Rankin scale. A total of 121 eligible cases were included: 61 (50.4%) exhibited good outcomes (modified Rankin scale score ≤2) by day 90. The logistic regression analysis showed that ipsilateral middle cerebral artery (iMCA) systolic blood flow (SBF) (OR = 0.983, 95% CI: 0.969–0.997, P = 0.014), preoperative National Institutes of Health Stroke Scale (NIHSS)score (OR = 1.160, 95% CI: 1.067–1.261, P < 0.001), intracranial hemorrhage after therapy (OR = 19.514, 95% CI: 4.364–87.265, P < 0.001), and Alberta Stroke Program Early Computed Tomography Score (OR = 0.639, 95% CI: 0.416–0.981, P = 0.040) were independently associated with prognosis. The iMCA SBF and preoperative NIHSS score were significantly predictive of a good outcome in the receiver operating characteristic analysis. In conclusion, elevated iMCA SBF might be a prognostic indicator of a good 90-day outcome following endovascular treatment in ACIS patients treated with mechanical thrombectomy, but large prospective studies are mandatory to validate the findings of our study.
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Affiliation(s)
- Tingting Wu
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , Hangzhou , 310014 , Zhejiang China
| | - Zongjie Shi
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , Hangzhou , 310014 , Zhejiang China
| | - Bo Chen
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , Hangzhou , 310014 , Zhejiang China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , Hangzhou , 310014 , Zhejiang China
| | - Jie Pan
- Department of Neurology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College) , No. 158 Shangtang Road , Hangzhou , 310014 , Zhejiang China
- Medical College of Soochow University , Suzhou , 215123 , China
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12
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Shimamura N, Naraoka M, Uchida K, Tokuda K, Sakai N, Imamura H, Yamagami H, Tanaka K, Ezura M, Nonaka T, Matsumoto Y, Shibata M, Ohta H, Morimoto M, Fukawa N, Hatano T, Enomoto Y, Takeuchi M, Ota T, Shimizu F, Kimura N, Kamiya Y, Morimoto T, Yoshimura S. Reperfusion Therapy Brings Apixaban Administration Forward in Patients with Nonvalvular Arterial Fibrillation with Anterior Circulation Large Vessel Occlusion or Stenosis. World Neurosurg 2022; 162:e503-e510. [PMID: 35304345 DOI: 10.1016/j.wneu.2022.03.036] [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: 12/17/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The initiation of anticoagulant administration after large vessel occlusion (LVO) or stenosis with nonvalvular arterial fibrillation (NAVF) is controversial. We evaluate the timing of anticoagulation and its relationship with clinical factors. METHODS We enrolled 595 anterior circulation LVO or stenosis with NAVF cases from 38 stroke centers. Laboratory data; activities of daily living; the Alberta Stroke Program Early CT Score (ASPECTS); the National Institutes of Health Stroke Scale (NIHSS) score; occluded artery; treatment methods; date of the initiation of apixaban administration and outcome were recorded. Multivariate analyses were performed after univariate analysis. RESULTS The median start of apixaban administration after the stroke was 2 days (interquartile range, 1-5; range, 0-14). Multivariate analysis of variance showed that non-internal carotid artery occlusion (F value 4.60), reperfusion therapy (31.1), high ASPECTS (6.27) before anticoagulant intake, and absence of intracranial hemorrhage (12.9) were significantly correlated with early apixaban administration. Multiple logistic regression analysis for independent living at 90 days after the stroke showed significant factors: aging (odds, 0.94; 95% confidence interval [CI], 0.91-0.97); male (odds, 0.46; 95% CI, 0.26-0.79); prestroke independence (odds, 20.7; 95% CI, 6.48-93.9); number of white blood cells (odds, 0.99; 95% CI, 0.97-1.00); non-internal carotid artery occlusion; NIHSS score at 72 hours after the stroke (odds 0.92; 95% CI, 0.89-0.96); ASPECTS before apixaban intake (odds, 1.15; 95% CI, 1.00-1.31) and initiation of apixaban (odds, 0.91; 95% CI, 0.83-0.99). CONCLUSIONS Early administration of apixaban is induced by nonsevere infarction, reperfusion therapy or none of intracranial hemorrhage and it correlates with an independent long-term outcome.
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Affiliation(s)
- Norihito Shimamura
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Masato Naraoka
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan; Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kou Tokuda
- Department of Neurosurgery, Nishinomiya Kyoritsu Hospital, Nishinomiya, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroshi Yamagami
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Tadashi Nonaka
- Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Miyagi, Japan
| | | | - Hajime Ohta
- Department of Neurosurgery, Division of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Norihito Fukawa
- Department of Neurosurgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Osaka, Japan
| | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | | | - Naoto Kimura
- Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
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13
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Deng G, Xiao J, Yu H, Chen M, Shang K, Qin C, Tian DS. Predictors of futile recanalization after endovascular treatment in acute ischemic stroke: a meta-analysis. J Neurointerv Surg 2021; 14:881-885. [PMID: 34544824 DOI: 10.1136/neurintsurg-2021-017963] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/24/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite successful recanalization after endovascular treatment, many patients with acute ischemic stroke due to large vessel occlusion still show functional dependence, namely futile recanalization. METHODS PubMed and Embase were searched up to April 30, 2021. Studies that reported risk factors for futile recanalization following endovascular treatment of acute ischemic stroke were included. The mean difference (MD) or odds ratio (OR) and 95% confidence interval (95% CI) of each study were pooled for a meta-analysis. RESULTS Twelve studies enrolling 2138 patients were included. The pooled analysis showed that age (MD 5.81, 95% CI 4.16 to 7.46), female sex (OR 1.40, 95% CI 1.16 to 1.68), National Institutes of Health Stroke Scale (NIHSS) score (MD 4.22, 95% CI 3.38 to 5.07), Alberta Stroke Program Early CT Score (ASPECTS) (MD -0.71, 95% CI -1.23 to -0.19), hypertension (OR 1.73, 95% CI 1.43 to 2.09), diabetes (OR 1.78, 95% CI 1.41 to 2.24), atrial fibrillation (OR 1.24, 95% CI 1.01 to 1.51), admission systolic blood pressure (MD 4.98, 95% CI 1.87 to 8.09), serum glucose (MD 0.59, 95% CI 0.37 to 0.81), internal carotid artery occlusion (OR 1.85, 95% CI 1.17 to 2.95), pre-treatment intravenous thrombolysis (OR 0.67, 95% CI 0.55 to 0.83), onset-to-puncture time (MD 16.92, 95% CI 6.52 to 27.31), puncture-to-recanalization time (MD 12.37, 95% CI 7.96 to 16.79), and post-treatment symptomatic intracerebral hemorrhage (OR 6.09, 95% CI 3.18 to 11.68) were significantly associated with futile recanalization. CONCLUSION This study identified female sex, comorbidities, admission systolic blood pressure, serum glucose, occlusion site, non-bridging therapy, and post-procedural complication as predictors of futile recanalization, and also confirmed previously reported factors. Further large-scale prospective studies are needed.
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Affiliation(s)
- Gang Deng
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jun Xiao
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Haihan Yu
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Man Chen
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ke Shang
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dai-Shi Tian
- Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
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14
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Katsumata M, Ota T, Kaneko J, Jimbo H, Aoki R, Fujitani S, Ichijo M, Inoue M, Shigeta K, Miyauchi Y, Sakai Y, Arakawa H, Otsuka Y, Ariyada K, Kuroshima Y, Fuse T, Shiokawa Y, Hirano T. Impact of Coronavirus Disease 2019 on Time Delay and Functional Outcome of Mechanical Thrombectomy in Tokyo, Japan. J Stroke Cerebrovasc Dis 2021; 30:106051. [PMID: 34419835 PMCID: PMC8361142 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/04/2021] [Accepted: 08/08/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives An association has been reported between delays in the onset-to-door (O2D) time for mechanical thrombectomy (MT) and outbreaks of coronavirus disease 2019 (COVID-19). However, the association between other MT time courses or functional outcomes and COVID-19 outbreaks remains unclear. We compared the time courses of stroke pathways or functional outcomes in 2020 (the COVID-19 era) with those in 2019 (the pre-COVID-19 era) in Tokyo, Japan. Materials and methods This retrospective observational study used data from the Tokyo-tama-REgistry of Acute endovascular Thrombectomy (TREAT), a multicenter registry of MT for acute large vessel occlusion in the Tokyo Metropolitan Area. Patients who had undergone acute MT from January 2019 to December 2020 were included. Patients were classified by the year they had undergone MT (2019 or 2020). Results In total, 477 patients were analyzed. O2D time was significantly longer in 2020 (146.0 min) than in 2019 (105.0 min; p = 0.034). No significant difference in door-to-puncture time (D2P) time or modified Rankin Scale (mRS) score 0–2 at 90 days was seen between 2019 and 2020. In the subgroup analysis, O2D time was significantly longer in the first half of 2020 compared with 2019. Multivariable logistic regression analysis revealed that the year 2020 was a independent predictor of longer O2D time, but not for mRS score 0–2 at 90 days. Conclusions Although O2D time was significantly longer in the COVID-19 compared with the pre-COVID-19 era, D2P may not be significantly delayed and functional outcomes may not be different, despite the COVID-19 pandemic.
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Affiliation(s)
- Masahiro Katsumata
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Hiroyuki Jimbo
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Rie Aoki
- Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Shigeta Fujitani
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Masahiko Ichijo
- Department of Neurology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Masato Inoue
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Yoshifumi Miyauchi
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yu Sakai
- Department of Neurosurgery, Showa General Hospital, Tokyo, Japan
| | - Hideki Arakawa
- Department of Neurosurgery, Omori Red Cross Hospital, Tokyo, Japan
| | - Yoshinobu Otsuka
- Department of Neurology, Machida Municipal Hospital, Tokyo, Japan
| | - Kenichi Ariyada
- Department of Neurosurgery, Tokyo Metropolitan Bokuto Hospital, Tokyo, Japan
| | | | - Takahisa Fuse
- Department of Neurosurgery, Public Fussa Hospital, Tokyo, Japan
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
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15
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Farooq J, Lee JY. Vascular tortuosity in endovascular mechanical thrombectomy. Brain Circ 2021; 7:3-7. [PMID: 34084969 PMCID: PMC8057096 DOI: 10.4103/bc.bc_5_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/02/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022] Open
Abstract
Endovascular mechanical thrombectomy effectively removes occlusive thrombi from the arterial lumen; however, there is little literature supporting the relevance of vascular geometry on surgical outcomes. Critical vessel characteristics including the degree of angulation and tortuosity influence the ability to advance stent retriever devices toward the site of occlusion. Therefore, it is crucial to evaluate the impact of carotid artery catheter pathway accessibility on the thrombectomy outcomes in acute ischemic stroke (AIS) patients. Traditional imaging modalities generate incomplete pictures of the vascular tortuosity and are prone to clinical judgment errors. Recent three-dimensional computed tomography angiography image analysis techniques circumvent these limitations to calculate accurate tortuosity and angulation measurements. These novel images facilitate classifying common anatomical variant patients into groups that may be treated with specially designed catheter devices. Importantly, this image analysis method reveals significant angulation in the common carotid artery and extracranial internal carotid artery that correlates with delays in reaching the occlusion site. Increased age, which is associated with increased risk of stroke, also increases the incidence of severe tortuosity. The semi-automated measurements technique also demonstrate that full 360° arterial loops are present in nearly 3% of catheter pathways and that the overall degree of angulation differs bilaterally. In this review, we examine the utility of this novel image analysis procedure and evaluate the recent literature relevant to neuroendovascular thrombectomy in AIS patients. Three literature databases – PubMed, Embase, and Web of Science were queried for original articles investigating both preclinical and clinical thrombectomy applications.
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Affiliation(s)
- Jeffrey Farooq
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jea Young Lee
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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