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Frol S, Pretnar Oblak J, Šabovič M, Ntaios G, Kermer P. Idarucizumab in dabigatran-treated patients with acute stroke: a review and clinical update. Front Neurol 2024; 15:1389283. [PMID: 38817549 PMCID: PMC11137220 DOI: 10.3389/fneur.2024.1389283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/19/2024] [Indexed: 06/01/2024] Open
Abstract
Idarucizumab is an antibody fragment specific for the immediate reversal of dabigatran anticoagulation effects. The use of idarucizumab is approved for dabigatran-treated patients suffering from life-threatening or uncontrolled bleeding and those in need of urgent surgery or invasive procedures. Data from randomized controlled clinical trials and real-world experience provide reassuring evidence about the efficacy and safety of idarucizmab use in patients with acute stroke. In this narrative review, we summarize the available real-world evidence and discuss the relevance and importance of idarucizumab treatment in acute stroke patients in everyday clinical practice. In addition, we also discuss special issues like prothrombin complex concentrate application as an alternative to idarucizumab, its application before endovascular therapy, sensitivity of thrombi to lysis, and necessary laboratory examinations.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Mišo Šabovič
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Vascular Disorders, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - George Ntaios
- Faculty of Medicine, Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Pawel Kermer
- Department of Neurology, Nordwest-Krankenhaus Sanderbusch, Friesland Kliniken GmbH, Sande, Germany
- University Medical Center Göttingen, Göttingen, Germany
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Knapen RRMM, Frol S, van Kuijk SMJ, Oblak JP, van der Leij C, van Oostenbrugge RJ, van Zwam WH. Intravenous thrombolysis for ischemic stroke in the posterior circulation: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107641. [PMID: 38395096 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107641] [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: 12/08/2023] [Revised: 02/06/2024] [Accepted: 02/18/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES Intravenous thrombolysis (IVT) is recommended in patients with ischemic stroke in the anterior and posterior circulation. Neurological outcomes due to posterior circulation strokes (PCS) without treatment remain poor. Our aim was to overview the literature on outcomes of IVT and conservative treatment in PCS, based on a systematic review and meta-analysis. METHODS A systematic literature search was performed on February 27th 2023. Outcome measures included favorable functional outcome at 90 days (modified Rankin Scale [mRS] 0-2), mortality at 90 days, and symptomatic intracranial hemorrhages (sICH). Weighted averages with DerSimonian-Laird approach was used to analyze the data. Subgroup analyses by time window were performed: standard time window (<4.5 hours after symptom onset) and extended time window (>4.5 hours). Analyses were performed using R. RESULTS Eight prospective and four retrospective cohort studies were included (n = 1589 patients); no studies with conservative treatment were eligible. The pooled weighted probability regarding favorable functional outcome after IVT was 63 % (95 %CI:0.45-0.78), for mortality 19 % (95 %CI:0.11-0.30), and for sICH 4 % (95 %CI:0.02-0.07). Subgroup analyses showed higher probabilities on achieving favorable functional outcomes for patients treated in the standard (77 %; 95 %CI:0.62-0.88) compared to the extended time window (38 %; 95 %CI:0.29-0.48) with RR = 1.93 (95 %CI:1.66-2.24). Lower probabilities regarding mortality at 90 days and sICH were seen in patients treated in standard compared to extended time window (RR = 0.42, 95 %CI:0.34-0.51 and RR = 0.27, 95 %CI:0.16-0.45, respectively). CONCLUSIONS IVT in patients with PCS seems to be safe and effective in standard and extended time window. The effect of IVT is higher in the standard time window.
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Affiliation(s)
- Robrecht R M M Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ and CARIM, School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands.
| | - Senta Frol
- Departmenta of Vascular Neurology, University Medical Center Ljubljana and Faculty of medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Janja Pretnar Oblak
- Departmenta of Vascular Neurology, University Medical Center Ljubljana and Faculty of medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Christiaan van der Leij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center+ and CARIM, School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+ and CARIM, School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
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Kappel AD, Nguyen HB, Frerichs KU, Patel NJ, Aziz-Sultan MA, Du R. Randomized Clinical Trials in Cerebrovascular Neurosurgery From 2018 to 2022. Cureus 2024; 16:e52397. [PMID: 38361699 PMCID: PMC10869144 DOI: 10.7759/cureus.52397] [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] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
There has been an exponential increase in randomized controlled trials (RCTs) on cerebrovascular disease within neurosurgery. The goal of this study was to review, outline the scope, and summarize all phase 2b and phase 3 RCTs impacting cerebrovascular neurosurgery practice since 2018. We searched PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for relevant RCTs published between January 1, 2018, and July 1, 2022. We searched for studies related to eight major cerebrovascular disorders relevant to neurosurgery, including acute ischemic stroke, cerebral aneurysms and subarachnoid hemorrhage, intracerebral hemorrhage, subdural hematomas, cerebral venous thrombosis, arteriovenous malformations, Moyamoya disease and extracranial-intracranial bypass, and carotid and intracranial atherosclerosis. We limited our search to phase 2b or 3 RCTs related to cerebrovascular disorders published during the study period. The titles and abstracts of all relevant studies meeting our search criteria were included. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. From an initial total of 2,797 records retrieved from the database searches, 1,641 records were screened after duplicates and studies outside of our time period were removed. After screening, 511 available reports within our time period of interest were assessed for eligibility. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. We found 80 unique phase 2b or 3 RCTs that fit our criteria, with 165 topic-relevant articles published within the study period. Numerous RCTs in cerebrovascular neurosurgery have been published since 2018. Ischemic stroke, including mechanical thrombectomy and thrombolysis, accounted for a majority of publications, but there were large trials in intracerebral hemorrhage, subdural hemorrhage, aneurysms, subarachnoid hemorrhage, and cerebral venous thrombosis, among others. This review helps define the scope of the large RCTs published in the last four years to guide future research and clinical care.
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Affiliation(s)
- Ari D Kappel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | | | - Nirav J Patel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | - Rose Du
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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Shafique MA, Ali SMS, Mustafa MS, Aamir A, Khuhro MS, Arbani N, Raza RA, Abbasi MB, Lucke-Wold B. Meta-analysis of direct endovascular thrombectomy vs bridging therapy in the management of acute ischemic stroke with large vessel occlusion. Clin Neurol Neurosurg 2024; 236:108070. [PMID: 38071760 DOI: 10.1016/j.clineuro.2023.108070] [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: 11/03/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Debates persist when using intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). This systematic review and meta-analysis synthesized evidence on outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), comparing bridging therapy (BT) with MT alone. METHOD We conducted searches of PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception to July 2023 to identify pertinent clinical trials and observational studies. RESULT 76 studies, involving 37,658 patients, revealed no significant difference in 90-day functional independence between DEVT and BT. However, a trend favoring BT for achieving functional independence with a modified Rankin Scale (mRS) of 0-1 was observed, having Odds ratio (OR) of 0.75 (95% CI 0.66-0.86; p < 0.001). DEVT was associated with higher postprocedural mortality (OR 1.44;95% CI 1.25-1.65; p < 0.001), but a lower risk of symptomatic intracranial hemorrhage compared to BT (OR 0.855; 95% CI 0.621-1.177; p = 0.327). Successful recanalization rates favored BT, emphasizing the importance of individualized treatment decisions (OR 0.759; 95% CI 0.594-0.969; p = 0.027). Sensitivity analyses were conducted to identify key contributors to heterogeneity. CONCLUSION Our meta-analysis underscores the intricate equilibrium between functional efficacy and safety in the evaluation of DEVT and BT for ACS-LVO. Fundamentally, while BT appears more efficacious, concerns about safety arise due to the superior safety profile demonstrated by DEVT. Individualized treatment decisions are imperative, and further trials are warranted to enhance precision in clinical guidance.
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Affiliation(s)
| | | | | | - Ali Aamir
- Department of Medicine, Dow University of Health Sciences, Pakistan.
| | | | - Naeemullah Arbani
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
| | - Rana Ali Raza
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
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Mujanovic A, Eker O, Marnat G, Strbian D, Ijäs P, Préterre C, Triquenot A, Albucher JF, Gauberti M, Weisenburger-Lile D, Ernst M, Nikoubashman O, Mpotsaris A, Gory B, Tuan Hua V, Ribo M, Liebeskind DS, Dobrocky T, Meinel TR, Buetikofer L, Gralla J, Fischer U, Kaesmacher J. Association of intravenous thrombolysis and pre-interventional reperfusion: a post hoc analysis of the SWIFT DIRECT trial. J Neurointerv Surg 2023; 15:e232-e239. [PMID: 36396433 PMCID: PMC10646907 DOI: 10.1136/jnis-2022-019585] [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: 08/30/2022] [Accepted: 10/13/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND A potential benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is pre-interventional reperfusion. Currently, there are few data on the occurrence of pre-interventional reperfusion in patients randomized to IVT or no IVT before MT. METHODS SWIFT DIRECT (Solitaire With the Intention For Thrombectomy Plus Intravenous t-PA vs DIRECT Solitaire Stent-retriever Thrombectomy in Acute Anterior Circulation Stroke) was a randomized controlled trial including acute ischemic stroke IVT eligible patients being directly admitted to a comprehensive stroke center, with allocation to IVT with MT versus MT alone. The primary endpoint of this analysis was the occurrence of pre-interventional reperfusion, defined as a pre-interventional expanded Thrombolysis in Cerebral Infarction score of ≥2a. The effect of IVT and potential treatment effect heterogeneity were analyzed using logistic regression analyses. RESULTS Of 396 patients, pre-interventional reperfusion occurred in 20 (10.0%) patients randomized to IVT with MT, and in 7 (3.6%) patients randomized to MT alone. Receiving IVT favored the occurrence of pre-interventional reperfusion (adjusted OR 2.91, 95% CI 1.23 to 6.87). There was no IVT treatment effect heterogeneity on the occurrence of pre-interventional reperfusion with different strata of Randomization-to-Groin-Puncture time (p for interaction=0.33), although the effect tended to be stronger in patients with a Randomization-to-Groin-Puncture time >28 min (adjusted OR 4.65, 95% CI 1.16 to 18.68). There were no significant differences in rates of functional outcomes between patients with and without pre-interventional reperfusion. CONCLUSION Even for patients with proximal large vessel occlusions and direct access to MT, IVT resulted in an absolute increase of 6% in rates of pre-interventional reperfusion. The influence of time strata on the occurrence of pre-interventional reperfusion should be studied further in an individual patient data meta-analysis of comparable trials. TRIAL REGISTRATION NUMBER clinicaltrials.gov NCT03192332.
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Affiliation(s)
- Adnan Mujanovic
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Omer Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, France
| | - Daniel Strbian
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Cécile Préterre
- Stroke Unit, University Hospital Centre Nantes, Nantes, France
| | - Aude Triquenot
- Department of Neurology, University Hospital Centre Rouen, Rouen, France
| | | | - Maxime Gauberti
- Department of Neuroradiology, University Hospital Centre Caen, Caen, France
| | - David Weisenburger-Lile
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Gottingen, Germany
| | | | | | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Nancy, Nancy, France
| | - Vi Tuan Hua
- Department of Neurology, University Hospital Centre Reims, Reims, France
| | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
| | | | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
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Bathla G, Ajmera P, Mehta PM, Benson JC, Derdeyn CP, Lanzino G, Agarwal A, Brinjikji W. Advances in Acute Ischemic Stroke Treatment: Current Status and Future Directions. AJNR Am J Neuroradiol 2023:ajnr.A7872. [PMID: 37202115 PMCID: PMC10337623 DOI: 10.3174/ajnr.a7872] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 04/03/2023] [Indexed: 05/20/2023]
Abstract
The management of acute ischemic stroke has undergone a paradigm shift in the past decade. This has been spearheaded by the emergence of endovascular thrombectomy, along with advances in medical therapy, imaging, and other facets of stroke care. Herein, we present an updated review of the various stroke trials that have impacted and continue to transform stroke management. It is critical for the radiologist to stay abreast of the ongoing developments to provide meaningful input and remain a useful part of the stroke team.
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Affiliation(s)
- G Bathla
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - P Ajmera
- Department of Radiology (P.A.), University College of Medical Sciences, Delhi, India
| | - P M Mehta
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - J C Benson
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - C P Derdeyn
- Department of Radiology (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - G Lanzino
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - A Agarwal
- Department of Radiology (A.A.), Mayo Clinic, Jacksonville, Florida
| | - W Brinjikji
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
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7
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Hoving JW, van Voorst H, Kappelhof M, Tolhuisen M, Treurniet KM, LeCouffe NE, Rinkel LA, Koopman MS, Cavalcante F, Konduri PR, van den Wijngaard IR, Ghariq E, Anton Meijer FJ, Coutinho JM, Marquering HA, Roos YBWEM, Emmer BJ, Majoie CBLM. Infarct Evolution in Patients with Anterior Circulation Large-Vessel Occlusion Randomized to IV Alteplase and Endovascular Treatment versus Endovascular Treatment Alone. AJNR Am J Neuroradiol 2023; 44:434-440. [PMID: 36958803 PMCID: PMC10084906 DOI: 10.3174/ajnr.a7826] [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: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Infarct evolution after endovascular treatment varies widely among patients with stroke and may be affected by baseline characteristics and procedural outcomes. Moreover, IV alteplase and endovascular treatment may influence the relationship of these factors to infarct evolution. We aimed to assess whether the infarct evolution between baseline and follow-up imaging was different for patients who received IVT and EVT versus EVT alone. MATERIALS AND METHODS We included patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN)-NO IV trial with baseline CTP and follow-up imaging. Follow-up infarct volume was segmented on 24-hour or 1-week follow-up DWI or NCCT. Infarct evolution was defined as the follow-up lesion volume: CTP core volume. Substantial infarct growth was defined as an increase in follow-up infarct volume of >10 mL. We assessed whether infarct evolution was different for patients with IV alteplase and endovascular treatment versus endovascular treatment alone and evaluated the association of baseline characteristics and procedural outcomes with infarct evolution using multivariable regression. RESULTS From 228 patients with CTP results available, 145 patients had follow-up imaging and were included in our analysis. For patients with IV alteplase and endovascular treatment versus endovascular treatment alone, the baseline median CTP core volume was 17 (interquartile range = 4-35) mL versus 11 (interquartile range = 6-24) mL. The median follow-up infarct volume was 13 (interquartile range, 4-48) mL versus 17 (interquartile range = 4-50) mL. Collateral status and occlusion location were negatively associated with substantial infarct growth in patients with and without IV alteplase before endovascular treatment. CONCLUSIONS No statistically significant difference in infarct evolution was found in directly admitted patients who received IV alteplase and endovascular treatment within 4.5 hours of symptom onset versus patients who underwent endovascular treatment alone. Collateral status and occlusion location may be useful predictors of infarct evolution prognosis in patients eligible for IV alteplase who underwent endovascular treatment.
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Affiliation(s)
- J W Hoving
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - H van Voorst
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - M Kappelhof
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - M Tolhuisen
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - K M Treurniet
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - N E LeCouffe
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - L A Rinkel
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - M S Koopman
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - F Cavalcante
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - P R Konduri
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - I R van den Wijngaard
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - E Ghariq
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - F J Anton Meijer
- Department of Radiology (F.J.A.M.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J M Coutinho
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - H A Marquering
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - Y B W E M Roos
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - B J Emmer
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - C B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
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Sheth SA. Mechanical Thrombectomy for Acute Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:443-461. [PMID: 37039404 DOI: 10.1212/con.0000000000001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Endovascular stroke therapy has greatly improved the ability to treat the deadliest and most disabling form of acute ischemic stroke. This article summarizes some of the recent innovations in this field and discusses likely future developments. LATEST DEVELOPMENTS At present, there is robust activity to improve all facets of care for patients with large vessel occlusion stroke, including better prehospital routing, more efficient in-hospital screening, expanding indications for thrombectomy eligibility, innovating novel thrombectomy devices, and improving the effects of recanalization on clinical outcomes. In addition, the integration of endovascular stroke therapy (EVT)-an emergent and frequently off-hours procedure that requires a specialized team of nurses, technologists, and physicians-into acute stroke care has transformed referral patterns, hospital accreditation pathways, and physician practices. The eligibility for the procedure will potentially continue to grow to include patients screened without advanced imaging, larger core infarcts, and more distal occlusions. ESSENTIAL POINTS In this review, we discuss the current state of EVT and its implications for practice, and present three cases that highlight some of the directions in which the field is moving.
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Kaesmacher J, Mujanovic A, Treurniet K, Kappelhof M, Meinel TR, Yang P, Liu J, Zhang Y, Zi W, Yang Q, Nogueira RG, Kimura K, Matsumaru Y, Suzuki K, Yan B, Mitchell PJ, Miao Z, Roos YBWEM, Majoie CBLM, Gralla J, Saver JL, Fischer U. Perceived acceptable uncertainty regarding comparability of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. J Neurointerv Surg 2023; 15:227-232. [PMID: 35232755 PMCID: PMC9985721 DOI: 10.1136/neurintsurg-2022-018665] [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: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Most trials comparing endovascular treatment (EVT) alone versus intravenous thrombolysis with alteplase (IVT) + EVT in directly admitted patients with a stroke are non-inferiority trials. However, the margin based on the level of uncertainty regarding non-inferiority of the experimental treatment that clinicians are willing to accept to incorporate EVT alone into clinical practice remains unknown. OBJECTIVE To characterize what experienced stroke clinicians would consider an acceptable level of uncertainty for hypothetical decisions on whether to administer IVT or not before EVT in patients admitted directly to EVT-capable centers. METHODS A web-based, structured survey was distributed to a cross-section of 600 academic neurologists/neurointerventionalists. For this purpose, a response framework for a hypothetical trial comparing IVT+EVT (standard of care) with EVT alone (experimental arm) was designed. In this trial, a similar proportion of patients in each arm achieved functional independence at 90 days. Invited physicians were asked at what level of certainty they would feel comfortable skipping IVT in clinical practice, considering these hypothetical trial results. RESULTS There were 180 respondents (response rate: 30%) and 165 with complete answers. The median chosen acceptable uncertainty suggesting reasonable comparability between both treatments was an absolute difference in the rate of day 90 functional independence of 3% (mode 5%, IQR 1-5%), with higher chosen margins observed in interventionalists (aOR 2.20, 95% CI 1.06 to 4.67). CONCLUSION Physicians would generally feel comfortable skipping IVT before EVT at different certainty thresholds. Most physicians would treat with EVT alone if randomized trial data suggested that the number of patients achieving functional independence at 90 days was similar between the two groups, and one could be sufficiently sure that no more than 3 out of 100 patients would not achieve functional independence at 90 days due to skipping IVT.
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Affiliation(s)
- Johannes Kaesmacher
- Department for Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Department for Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, Bern, Switzerland.,Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University, Shanghai, China
| | - Wenjie Zi
- Department of Neurology, Army Medical University Xinqiao Hospital, Chongqing, Sichuan, China
| | - Qingwu Yang
- Department of Neurology, Army Medical University Xinqiao Hospital, Chongqing, Sichuan, China
| | - Raul G Nogueira
- Department of Neurology, Grady Memorial Hospital, Chickasha, Oklahoma, USA
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Bernard Yan
- Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Jan Gralla
- Department for Diagnostic and Interventional Neuroradiology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Jeffrey L Saver
- Department of Neurology, UCLA, Los Angeles, California, USA.,Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
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10
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Intravenous thrombolysis prior to endovascular treatment for acute ischemic stroke: a meta-analysis. Neurol Sci 2022; 43:5993-6002. [DOI: 10.1007/s10072-022-06233-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
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11
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Mitchell PJ, Yan B, Churilov L, Dowling RJ, Bush SJ, Bivard A, Huo XC, Wang G, Zhang SY, Ton MD, Cordato DJ, Kleinig TJ, Ma H, Chandra RV, Brown H, Campbell BCV, Cheung AK, Steinfort B, Scroop R, Redmond K, Miteff F, Liu Y, Duc DP, Rice H, Parsons MW, Wu TY, Nguyen HT, Donnan GA, Miao ZR, Davis SM. Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial. Lancet 2022; 400:116-125. [PMID: 35810757 DOI: 10.1016/s0140-6736(22)00564-5] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND The benefit of combined treatment with intravenous thrombolysis before endovascular thrombectomy in patients with acute ischaemic stroke caused by large vessel occlusion remains unclear. We hypothesised that the clinical outcomes of patients with stroke with large vessel occlusion treated with direct endovascular thrombectomy within 4·5 h would be non-inferior compared with the outcomes of those treated with standard bridging therapy (intravenous thrombolysis before endovascular thrombectomy). METHODS DIRECT-SAFE was an international, multicentre, prospective, randomised, open-label, blinded-endpoint trial. Adult patients with stroke and large vessel occlusion in the intracranial internal carotid artery, middle cerebral artery (M1 or M2), or basilar artery, confirmed by non-contrast CT and vascular imaging, and who presented within 4·5 h of stroke onset were recruited from 25 acute-care hospitals in Australia, New Zealand, China, and Vietnam. Eligible patients were randomly assigned (1:1) via a web-based, computer-generated randomisation procedure stratified by site of baseline arterial occlusion and by geographic region to direct endovascular thrombectomy or bridging therapy. Patients assigned to bridging therapy received intravenous thrombolytic (alteplase or tenecteplase) as per standard care at each site; endovascular thrombectomy was also per standard of care, using the Trevo device (Stryker Neurovascular, Fremont, CA, USA) as first-line intervention. Personnel assessing outcomes were masked to group allocation; patients and treating physicians were not. The primary efficacy endpoint was functional independence defined as modified Rankin Scale score 0-2 or return to baseline at 90 days, with a non-inferiority margin of -0·1, analysed by intention to treat (including all randomly assigned and consenting patients) and per protocol. The intention-to-treat population was included in the safety analyses. The trial is registered with ClinicalTrials.gov, NCT03494920, and is closed to new participants. FINDINGS Between June 2, 2018, and July 8, 2021, 295 patients were randomly assigned to direct endovascular thrombectomy (n=148) or bridging therapy (n=147). Functional independence occurred in 80 (55%) of 146 patients in the direct thrombectomy group and 89 (61%) of 147 patients in the bridging therapy group (intention-to-treat risk difference -0·051, two-sided 95% CI -0·160 to 0·059; per-protocol risk difference -0·062, two-sided 95% CI -0·173 to 0·049). Safety outcomes were similar between groups, with symptomatic intracerebral haemorrhage occurring in two (1%) of 146 patients in the direct group and one (1%) of 147 patients in the bridging group (adjusted odds ratio 1·70, 95% CI 0·22-13·04) and death in 22 (15%) of 146 patients in the direct group and 24 (16%) of 147 patients in the bridging group (adjusted odds ratio 0·92, 95% CI 0·46-1·84). INTERPRETATION We did not show non-inferiority of direct endovascular thrombectomy compared with bridging therapy. The additional information from our study should inform guidelines to recommend bridging therapy as standard treatment. FUNDING Australian National Health and Medical Research Council and Stryker USA.
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Affiliation(s)
- Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Melbourne Medical School, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Richard J Dowling
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Steven J Bush
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Andrew Bivard
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Xiao Chuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
| | - Guoqing Wang
- Department of Neurology, Bin Zhou People's Hospital, Shandong Province, China
| | - Shi Yong Zhang
- Department of Interventional Neuroradiology, Beijing Fengtai You'anmen Hospital, Beijing, China
| | - Mai Duy Ton
- Stroke Centre, Bach Mai Hospital, Ha Noi Medical University, Ha Noi, Vietnam
| | - Dennis J Cordato
- Department of Neurology, Liverpool Hospital, University of New South Wales, Liverpool, Sydney, NSW, Australia; South Western Sydney Clinical School, University of New South Wales Medicine, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Sydney, NSW, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Monash Health Centre, Clayton, VIC, Australia
| | - Ronil V Chandra
- NeuroInterventional Radiology, Department of Imaging, School of Clinical Sciences, Monash University, Monash Health Centre, Clayton, VIC, Australia
| | - Helen Brown
- Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Florey Institute of Neuroscience and Mental Health, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Andrew K Cheung
- Department of Neurointerventional Radiology, Liverpool Hospital, University of New South Wales, Liverpool, Sydney, NSW, Australia; South West Sydney Clinical Campuses, University of New South Wales Medicine, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Sydney, NSW, Australia
| | - Brendan Steinfort
- Department of Neurosurgery, Neurointervention Unit, Interventional Neuroradiology Department, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Rebecca Scroop
- Department of Radiology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kendal Redmond
- Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - Yan Liu
- Department of Neurology, JingJiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, Jiangsu, China
| | - Dang Phuc Duc
- Department of Stroke, Military Hospital 103, Ha Noi, Vietnam
| | - Hal Rice
- Department of Neurointervention, Gold Coast University Hospital, Southport, QLD, Australia
| | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales, Liverpool, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, Sydney, NSW, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Huy-Thang Nguyen
- Pham Ngoc Thach University of Medicine, The People's Hospital 115, Ho Chi Minh, Vietnam
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Zhong Rong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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12
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Derraz I. The End of Tissue-Type Plasminogen Activator's Reign? Stroke 2022; 53:2683-2694. [PMID: 35506385 DOI: 10.1161/strokeaha.122.039287] [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
Mechanical thrombectomy is a highly effective treatment for acute ischemic stroke caused by large-vessel occlusion in the anterior cerebral circulation, significantly increasing the likelihood of recovery to functional independence. Until recently, whether intravenous thrombolysis before mechanical thrombectomy provided additional benefits to patients with acute ischemic stroke-large-vessel occlusion remained unclear. Given that reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke-large-vessel occlusion and the efficacy of both intravenous thrombolysis and mechanical thrombectomy is time-dependent, achieving complete reperfusion with a single pass should be the primary angiographic goal. However, it remains undetermined whether extending the procedure with additional endovascular attempts or local lytics administration safely leads to higher reperfusion grades and whether there are significant public health and cost implications. Here, we outline the current state of knowledge and research avenues that remain to be explored regarding the consistent therapeutic benefit of intravenous thrombolysis in anterior circulation strokes and the potential place of adjunctive intra-arterial lytics administration, including alternative thrombolytic agent place.
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Affiliation(s)
- Imad Derraz
- Department of Neuroradiology, Hôpital Guide Chauliac, Montpellier University Medical Center, France
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