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Arrarte Terreros N, Stolp J, Bruggeman AAE, Swijnenburg ISJ, Lopes RR, van Meenen LCC, Groot AED, Kappelhof M, Coutinho JM, Roos YBWEM, Emmer BJ, Beenen LFM, Dippel DWJ, van Zwam WH, van Bavel E, Marquering HA, Majoie CBLM. Thrombus Imaging Characteristics to Predict Early Recanalization in Anterior Circulation Large Vessel Occlusion Stroke. J Cardiovasc Dev Dis 2024; 11:107. [PMID: 38667725 PMCID: PMC11050543 DOI: 10.3390/jcdd11040107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
The early management of transferred patients with a large vessel occlusion (LVO) stroke could be improved by identifying patients who are likely to recanalize early. We aim to predict early recanalization based on patient clinical and thrombus imaging characteristics. We included 81 transferred anterior-circulation LVO patients with an early recanalization, defined as the resolution of the LVO or the migration to a distal location not reachable with endovascular treatment upon repeated radiological imaging. We compared their clinical and imaging characteristics with all (322) transferred patients with a persistent LVO in the MR CLEAN Registry. We measured distance from carotid terminus to thrombus (DT), thrombus length, density, and perviousness on baseline CT images. We built logistic regression models to predict early recanalization. We validated the predictive ability by computing the median area-under-the-curve (AUC) of the receiver operating characteristics curve for 100 5-fold cross-validations. The administration of intravenous thrombolysis (IVT), longer transfer times, more distal occlusions, and shorter, pervious, less dense thrombi were characteristic of early recanalization. After backward elimination, IVT administration, DT and thrombus density remained in the multivariable model, with an AUC of 0.77 (IQR 0.72-0.83). Baseline thrombus imaging characteristics are valuable in predicting early recanalization and can potentially be used to optimize repeated imaging workflow.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jeffrey Stolp
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Agnetha A. E. Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Isabella S. J. Swijnenburg
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ricardo R. Lopes
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Laura C. C. van Meenen
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Adrien E. D. Groot
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Manon Kappelhof
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Yvo B. W. E. M. Roos
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
| | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Checkouri T, Gerschenfeld G, Seners P, Yger M, Ben Hassen W, Chausson N, Olindo S, Caroff J, Marnat G, Clarençon F, Baron JC, Turc G, Alamowitch S. Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase. Stroke 2023; 54:2491-2499. [PMID: 37622385 DOI: 10.1161/strokeaha.123.042691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) with alteplase or tenecteplase before mechanical thrombectomy is the recommended treatment for large-vessel occlusion acute ischemic stroke. There are divergent data on whether these agents differ in terms of early recanalization (ER) rates before mechanical thrombectomy, and little data on their potential differences stratified by ER predictors such as IVT to ER evaluation (IVT-to-EReval) time, occlusion site and thrombus length. METHODS We retrospectively compared the likelihood of ER after IVT with tenecteplase or alteplase in anterior circulation large-vessel occlusion acute ischemic stroke patients from the PREDICT-RECANAL (alteplase) and Tenecteplase Treatment in Ischemic Stroke (tenecteplase) French multicenter registries. ER was defined as a modified Thrombolysis in Cerebral Infarction score 2b-3 on the first angiographic run, or noninvasive vascular imaging in patients with early neurological improvement. Analyses were based on propensity score overlap weighting (leading to exact balance in patient history, stroke characteristics, and initial management between groups) and confirmed with adjusted logistic regression (sensitivity analysis). A stratified analysis based on pre-established ER predictors (IVT-to-EReval time, occlusion site, and thrombus length) was conducted. RESULTS Overall, 1865 patients were included. ER occurred in 156/787 (19.8%) and 199/1078 (18.5%) patients treated with tenecteplase or alteplase, respectively (odds ratio, 1.09 [95% CI, 0.83-1.44]; P=0.52). A differential effect of tenecteplase versus alteplase on the probability of ER according to thrombus length was observed (Pinteraction=0.003), with tenecteplase being associated with higher odds of ER in thrombi >10 mm (odds ratio, 2.43 [95% CI, 1.02-5.81]; P=0.04). There was no differential effect of tenecteplase versus alteplase on the likelihood of ER according to the IVT-to-EReval time (Pinteraction=0.40) or occlusion site (Pinteraction=0.80). CONCLUSIONS Both thrombolytics achieved ER in one-fifth of patients with large-vessel occlusion acute ischemic stroke without significant interaction with IVT-to-EReval time and occlusion site. Compared with alteplase, tenecteplase was associated with a 2-fold higher likelihood of ER in larger thrombi.
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Affiliation(s)
- Thomas Checkouri
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Gaspard Gerschenfeld
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Pierre Seners
- Service de Neurologie, GHU Paris Psychiatrie et Neurosciences, France (P.S.)
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neurologie, Hôpital Fondation Rothschild, Paris, France (P.S.)
| | - Marion Yger
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Wagih Ben Hassen
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, France (W.B.H.)
| | - Nicolas Chausson
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neurologie, Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes (N.C.)
| | | | - Jildaz Caroff
- AP-HP, Service de Neuroradiologie interventionnelle (NEURI), Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France (J.C.)
| | - Gaultier Marnat
- Service de Neuroradiologie diagnostique et interventionnelle (G.M.), France
- CHU de Bordeaux, France (G.M.)
| | - Frédéric Clarençon
- AP-HP, Service de Neuroradiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France (F.C.)
| | - Jean-Claude Baron
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
| | - Guillaume Turc
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
| | - Sonia Alamowitch
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
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Arrarte Terreros N, Bruggeman AA, Kappelhof M, Tolhuisen ML, Brouwer J, Hoving JW, Konduri PR, van Kranendonk KR, Dutra BG, Alves HC, Dippel DW, van Zwam WH, Beenen LF, Yo LS, van Bavel E, Majoie CB, Marquering HA. Thrombus imaging characteristics within acute ischemic stroke: similarities and interdependence. J Neurointerv Surg 2023; 15:e60-e68. [PMID: 35835463 PMCID: PMC10715487 DOI: 10.1136/jnis-2022-019134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/23/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The effects of thrombus imaging characteristics on procedural and clinical outcomes after ischemic stroke are increasingly being studied. These thrombus characteristics - for eg, size, location, and density - are commonly analyzed as separate entities. However, it is known that some of these thrombus characteristics are strongly related. Multicollinearity can lead to unreliable prediction models. We aimed to determine the distribution, correlation and clustering of thrombus imaging characteristics based on a large dataset of anterior-circulation acute ischemic stroke patients. METHODS We measured thrombus imaging characteristics in the MR CLEAN Registry dataset, which included occlusion location, distance from the intracranial carotid artery to the thrombus (DT), thrombus length, density, perviousness, and clot burden score (CBS). We assessed intercorrelations with Spearman's coefficient (ρ) and grouped thrombi based on 1) occlusion location and 2) thrombus length, density and perviousness using unsupervised clustering. RESULTS We included 934 patients, of which 22% had an internal carotid artery (ICA) occlusion, 61% M1, 16% M2, and 1% another occlusion location. All thrombus characteristics were significantly correlated. Higher CBS was strongly correlated with longer DT (ρ=0.67, p<0.01), and moderately correlated with shorter thrombus length (ρ=-0.41, p<0.01). In more proximal occlusion locations, thrombi were significantly longer, denser, and less pervious. Unsupervised clustering analysis resulted in four thrombus groups; however, the cohesion within and distinction between the groups were weak. CONCLUSIONS Thrombus imaging characteristics are significantly intercorrelated - strong correlations should be considered in future predictive modeling studies. Clustering analysis showed there are no distinct thrombus archetypes - novel treatments should consider this thrombus variability.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Agnetha Ae Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Manon L Tolhuisen
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Josje Brouwer
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Praneeta R Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Katinka R van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Bruna G Dutra
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Heitor Cbr Alves
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht UMC, Maastricht, The Netherlands
| | - Ludo Fm Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Lonneke Sf Yo
- Department of Radiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
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Schlemm L, Siebert E, Kleine JF, Riegler C, Bode FJ, Petersens M, Schlemm E, Keil F, Tiedt S, Bohner G, Nolte CH. Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry. Eur Stroke J 2023; 8:610-617. [PMID: 37243508 PMCID: PMC10472953 DOI: 10.1177/23969873231177774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/07/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. METHODS Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. RESULTS 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%-3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%-1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%-2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. CONCLUSION We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.
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Affiliation(s)
- Ludwig Schlemm
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fee Keil
- Institute for Neuroradiology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
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5
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Ho-Tin-Noé B, Desilles JP, Mazighi M. Thrombus composition and thrombolysis resistance in stroke. Res Pract Thromb Haemost 2023; 7:100178. [PMID: 37538503 PMCID: PMC10394565 DOI: 10.1016/j.rpth.2023.100178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 08/05/2023] Open
Abstract
A State of the Art lecture titled "Thrombus Composition and Thrombolysis Resistance in Stroke" was presented at the ISTH Congress in 2022. Intravenous thrombolysis (IVT) remains the only pharmacologic option to re-establish cerebral perfusion at the acute phase of ischemic stroke. IVT is based on the administration of recombinant tissue plasminogen activator with the objective of dissolving fibrin, the major fibrillar protein component of thrombi. Almost 30 years on from its introduction, although the clinical benefits of IVT have been clearly demonstrated, IVT still suffers from a relatively low efficacy, with a rate of successful early recanalization below 50% overall. Analyses of thrombectomy-recovered acute ischemic stroke (AIS) thrombi have shown that apart from occlusion site, thrombus length, and collateral status, AIS thrombus structure and composition are also important modulators of IVT efficacy. In this article, after a brief presentation of IVT principle and current knowledge on IVT resistance, we review recent findings on how compaction and structural alterations of fibrin together with nonfibrin thrombus components such as neutrophil extracellular traps and von Willebrand factor interfere with IVT in AIS. We further discuss how these new insights could soon result in the development of original adjuvant therapies for improved IVT in AIS. Finally, we summarize relevant new data presented during the 2022 ISTH Congress.
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Affiliation(s)
- Benoit Ho-Tin-Noé
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Jean-Philippe Desilles
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
| | - Mikael Mazighi
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
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6
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Feil K, Matusevicius M, Herzberg M, Tiedt S, Küpper C, Wischmann J, Schönecker S, Mengel A, Sartor‐Pfeiffer J, Berger K, Dimitriadis K, Liebig T, Dieterich M, Mazya M, Ahmed N, Kellert L. Minor stroke in large vessel occlusion: A matched analysis of patients from the German Stroke Registry-Endovascular Treatment (GSR-ET) and patients from the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Eur J Neurol 2022; 29:1619-1629. [PMID: 35122371 PMCID: PMC9306813 DOI: 10.1111/ene.15272] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Reperfusion treatment in patients presenting with large vessel occlusion (LVO) and minor neurological deficits is still a matter of debate. We aimed to compare minor stroke patients treated with endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or IVT alone. METHODS Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) and the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) between June 2015 and December 2019 were analyzed. Minor stroke was defined as National Institutes of Health Stroke Scale (NIHSS) score ≤5, and LVO as occlusion of the internal carotid, carotid-T, middle cerebral, basilar, vertebral or posterior cerebral arteries. GSR-ET and SITS-ISTR IVT-treated patients were matched in a 1:1 ratio using propensity-score (PS) matching. The primary outcome was good functional outcome at 3 months (modified Rankin Scale score 0-2). RESULTS A total of 272 GSR-ET patients treated with EVT and IVT (age 68.6 ± 14.0 years, 43.4% female, NIHSS score 4 [interquartile range 2-5]) were compared to 272 IVT-treated SITS-ISTR patients (age 69.4 ± 13.7, 43.4% female, NIHSS score 4 [2-5]). Good functional outcome was seen in 77.0% versus 82.9% (p = 0.119), mortality in 5.9% versus 7.9% (p = 0.413), and intracranial hemorrhage in 8.8% versus 12.5% (p = 0.308) of patients in the GSR-ET versus the SITS-ISTR IVT group, respectively. In a second PS-matched analysis, 624 GSR-ET patients (IVT rate 56.7%) and 624 SITS-ISTR patients (IVT rate 100%), good outcome was more often observed in the SITS-ISTR patients (68.2% vs. 80.9%; p < 0.001), and IVT independently predicted good outcome (odds ratio 2.16, 95% confidence interval 1.43-3.28). CONCLUSIONS Our study suggests similar effectiveness of IVT alone compared to EVT with or without IVT in minor stroke patients. There is an urgent need for randomized controlled trials on this topic.
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Affiliation(s)
- Katharina Feil
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Marius Matusevicius
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of Research and EducationKarolinska University HospitalStockholmSweden
| | - Moriz Herzberg
- Institute of NeuroradiologyLMUMunichGermany,Department of RadiologyUniversity HospitalWuerzburgGermany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | - Clemens Küpper
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Johannes Wischmann
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Sonja Schönecker
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Annerose Mengel
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Jennifer Sartor‐Pfeiffer
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Katharina Berger
- Department of Neurology and EpileptologyEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Konstantin Dimitriadis
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | | | - Marianne Dieterich
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Munich Cluster for Systems Neurology (SyNergy)MunichGermany,German Center for Vertigo and Balance DisordersLMUMunichGermany
| | - Michael Mazya
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Niaz Ahmed
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Lars Kellert
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
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Zhou Y, Zhang L, Ospel J, Goyal M, McDonough R, Xing P, Li Z, Zhang X, Zhang Y, Zhang Y, Hong B, Xu Y, Huang Q, Li Q, Yu Y, Zuo Q, Ye X, Yang P, Liu J. Association of Intravenous Alteplase, Early Reperfusion, and Clinical Outcome in Patients With Large Vessel Occlusion Stroke: Post Hoc Analysis of the Randomized DIRECT-MT Trial. Stroke 2022; 53:1828-1836. [PMID: 35240861 DOI: 10.1161/strokeaha.121.037061] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The added value of intravenous alteplase in reperfusing ischemic brain tissue in patients undergoing endovascular treatment and directly presented to an endovascular treatment-capable hospital is uncertain. We conducted this post hoc analysis of a randomized trial (DIRECT-MT [Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: A Multicenter Randomized Clinical Trial]) to explore the association of intravenous alteplase, early (preendovascular treatment) reperfusion, and clinical outcome and to determine factors which may modify alteplase treatment effect on early reperfusion. METHODS In this post hoc analysis of the DIRECT-MT randomized trial comparing intravenous alteplase before endovascular treatment versus endovascular treatment only, 623 of 656 randomized patients, with adequate angiographic evaluation for early reperfusion assessment, were included. The association of intravenous alteplase and early reperfusion (defined as expanded Thrombolysis in Cerebral Infarction score ≥2a on angiogram) was assessed using unadjusted comparisons and multivariable logistic regression. RESULTS Among 623 patients included (317 received intravenous alteplase and 306 did not), early reperfusion occurred in 91 (15%) patients and was associated with better functional outcome (modified Rankin Scale score, 0-2 of 49/91 [54%] versus 178/531 [34%]; adjusted odds ratio, 1.92 [95% CI, 1.15-3.21]; P<0.001). Intravenous alteplase was independently associated with early reperfusion (59/317 [19%] versus 32/306 [10%]; adjusted odds ratio, 2.06 [95% CI, 1.27-3.33]; P=0.003), and the alteplase effect was modified by time from randomization to groin puncture (dichotomized by median, ≤33 minutes; adjusted odds ratio, 1.06 [95% CI, 0.53-2.10] versus >33 minutes; adjusted odds ratio, 4.07 [95% CI, 1.86-8.86]; Pinteraction=0.012). CONCLUSIONS For patients with large vessel occlusion directly presenting to an endovascular treatment-capable hospital, intravenous alteplase increases early reperfusion when endovascular treatment gets delayed more than approximately half an hour. Thus, intravenous alteplase should be considered if endovascular treatment delays are anticipated by the treating medical team. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03469206.
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Affiliation(s)
- Yu Zhou
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Johanna Ospel
- Department of Radiology, University Hospital Basel, Switzerland (J.O.)
| | - Mayank Goyal
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Canada (M.G., R.M.)
| | - Rosalie McDonough
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Canada (M.G., R.M.).,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Germany (R.M.)
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Xiaoxi Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongxin Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Bo Hong
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yi Xu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qinghai Huang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiang Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Ying Yu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiao Zuo
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Xiaofei Ye
- Health Statistics Department, Naval Medical University, Shanghai, China (X.Y.)
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
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Cohen C, Gaillot K, Ifergan H, Dejobert M, Gaudron M, Molinier E, Amelot A, Cottier JP, Bibi R, Janot K, Magni C, Narata AP, Boulouis G. Quantitative analysis of thrombus migration before mechanical thrombectomy: Determinants and relationship with procedural and clinical outcomes. J Neuroradiol 2021:S0150-9861(21)00169-3. [PMID: 34808221 DOI: 10.1016/j.neurad.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS) and a large vessel occlusion (LVO), thrombus migration (T-Mig) is a common phenomenon before mechanical thrombectomy (MT), revealed by pre-treatment imaging. Previous works have used qualitative scales to define T-Mig. The aim of this study was to evaluate the determinants and impact of quantitatively assessed T-Mig on procedural characteristics and clinical outcome. METHODS Consecutive patients with AIS due to LVO treated by MT at a reference academic hospital were analysed. Distance between vessel origin and beginning of the thrombus on MRI (3D-time-of-flight and/or contrast-enhanced magnetic-resonance-angiography) and digital-substracted-angiography (DSA) were measured in millimeters using a curve tool. Thrombus migration was defined quantitatively as ∆TD calculated as the difference between pre-MT-DSA and MRI thrombus location. ∆TD was rated as significant if above 5mm. RESULTS A total of 267 patients were included (mean age 70±12 years; 46% females) were analyzed. Amongst them, 65 (24.3%) experienced any degree of T-Mig. T-Mig was found to be associated with iv-tPA administration prior to thrombectomy (β-estimate 2.52; 95% CI [1.25-3.79]; p<0.001), fewer device passes during thrombectomy (1.22±1.31 vs 1.66±0.99; p<0.05), and shorter pre-treatment thrombi (β-estimate -0.1millimeter; 95% CI [-0.27-0.07]; p<0.05). There was no association between T-Mig and a favourable outcome (defined by a 0-to-2 modified-Rankin-Scale at 3months, adjusted OR: 2.16 [0.93 - 5.02]; p=0.06) CONCLUSION: Thrombus migration happens in almost a fourth of our study sample, and its quantitative extent was associated with iv-tPA administration prior to MT, but not with clinical outcome.
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Lau HL, Gardener H, Coutts SB, Saini V, Field TS, Dowlatshahi D, Smith EE, Hill MD, Romano JG, Demchuk AM, Menon BK, Asdaghi N. Radiographic Characteristics of Mild Ischemic Stroke Patients With Visible Intracranial Occlusion: The INTERRSeCT Study. Stroke 2021; 53:913-920. [PMID: 34753303 DOI: 10.1161/strokeaha.120.030380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Early neurological deterioration occurs in one-third of mild strokes primarily due to the presence of a relevant intracranial occlusion. We studied vascular occlusive patterns, thrombus characteristics, and recanalization rates in these patients. METHODS Among patients enrolled in INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography), a multicenter prospective study of acute ischemic strokes with a visible intracranial occlusion, we compared characteristics of mild (National Institutes of Health Stroke Scale score, ≤5) to moderate/severe strokes. RESULTS Among 575 patients, 12.9% had a National Institutes of Health Stroke Scale score ≤5 (median age, 70.5 [63-79]; 58% male; median National Institutes of Health Stroke Scale score, 4 [2-4]). Demographics and vascular risk factors were similar between the two groups. As compared with those with a National Institutes of Health Stroke Scale score >5, mild patients had longer symptom onset to assessment times (onset to computed tomography [240 versus 167 minutes] and computed tomography angiography [246 versus 172 minutes]), more distal occlusions (M3, anterior cerebral artery and posterior cerebral artery; 22% versus 6%), higher clot burden score (median, 9 [6-9] versus 6 [4-9]), similar favorable thrombus permeability (residual flow grades I-II, 21% versus 19%), higher collateral flow (9.1 versus 7.6), and lower intravenous alteplase treatment rates (55% versus 85%). Mild patients were more likely to recanalize (revised arterial occlusion scale score 2b/3, 45%; 49% with alteplase) compared with moderate/severe strokes (26%; 29% with alteplase). In an adjusted model for sex, alteplase, residual flow, and time between the two vessel imagings, intravenous alteplase use (odds ratio, 3.80 [95% CI, 1.11-13.00]) and residual flow grade (odds ratio, 8.70 [95% CI, 1.26-60.13]) were associated with successful recanalization among mild patients. CONCLUSIONS Mild strokes with visible intracranial occlusions have different vascular occlusive patterns but similar thrombus permeability compared with moderate/severe strokes. Higher thrombus permeability and alteplase use were associated with successful recanalization, although the majority do not recanalize. Randomized controlled trials are needed to assess the efficacy of new thrombolytics and endovascular therapy in this population.
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Affiliation(s)
- H Lee Lau
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
| | - Hannah Gardener
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Vasu Saini
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
| | - Thalia S Field
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada (T.S.F.)
| | - Dar Dowlatshahi
- Department of Neuroscience, Ottawa Hospital Research Institute, Ontario, Canada (D.D.).,Department of Epidemiology, Ottawa Hospital Research Institute, Ontario, Canada (D.D.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Jose G Romano
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Negar Asdaghi
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
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He L, Wang J, Wang F, Zhang L, Zhang L, Zhao W, Weng X, Xu F. The length of susceptibility vessel sign predicts early neurological deterioration in minor acute ischemic stroke with large vessel occlusion. BMC Neurol 2021; 21:421. [PMID: 34715818 PMCID: PMC8557057 DOI: 10.1186/s12883-021-02455-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/21/2021] [Indexed: 02/08/2023] Open
Abstract
Background Patients with acute large vessel occlusion (LVO) presenting with minor stroke are at risk of early neurological deterioration (END). The present study aimed to evaluate the frequency and potential predictors of END in patients with medical management and LVO presenting with minor stroke. The relationship between SVS length and END was also investigated. Methods This was a prospective multicenter study. Consecutive patients were collected with anterior circulation. LVO presented with minor stroke [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] within 24 h following onset. END was defined as a deterioration of NIHSS ≥4 within 24 h, without parenchymal hemorrhage. The length of the susceptibility vessel sign (SVS) was measured using the T2* gradient echo imaging. Results A total of 134 consecutive patients with anterior circulation LVO presenting with minor stroke were included. A total of 27 (20.15%) patients experienced END following admission. Patients with END exhibited longer SVS and higher baseline glucose levels compared with subjects lacking END (P < 0.05). ROC curve analysis indicated that the optimal cutoff point SVS length for END was SVS ≥ 9.45 mm. Multivariable analysis indicated that longer SVS [adjusted odds ratio (aOR), 2.03; 95% confidence interval (CI), 1.45–2.84; P < 0.001] and higher baseline glucose (aOR,1.02; 95% CI, 1.01–1.03; P = 0.009) levels were associated with increased risk of END. When SVS ≥ 9.45 mm was used in the multivariate logistic regression, SVS ≥ 9.45 mm (aOR, 5.41; 95%CI, 1.00–29.27; P = 0.001) and higher baseline glucose [aOR1.01; 95%CI, 1.00–1.03; P = 0.021] were associated with increased risk of END. Conclusions END was frequent in the minor stroke patients with large vessel occlusion, whereas longer SVS and higher baseline glucose were associated with increased risk of END. SVS ≥ 9.45 mm was a powerful independent predictor of END.
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Affiliation(s)
- Lanying He
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Jian Wang
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Feng Wang
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Lili Zhang
- Department of Neurology, The Second People's Hospital of Chengdu, Chengdu, 610021, People's Republic of China
| | - Lijuan Zhang
- Department of Neurology, The Second Affiliated Hospital of Chengdu College, Nuclear Industry 416 Hospital, Chengdu, 610021, People's Republic of China
| | - Wang Zhao
- Department of Neurology, Yongchuan Hospital, Chongqing Medical University, Chongqing, 610020, People's Republic of China
| | - Xiechuan Weng
- Beijing Institute of Basic Medical Sciences, Beijing, 100850, China.
| | - Fan Xu
- School of Public Health Chengdu Medical College, Chengdu, 610500, Sichuan, China.
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Malhotra A, Khunte M. Reader Response: Thrombectomy vs Medical Management in Low NIHSS Acute Anterior Circulation Stroke. Neurology 2021; 97:559-560. [PMID: 34518328 DOI: 10.1212/wnl.0000000000012552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Gauberti M, Martinez de Lizarrondo S, Vivien D. Thrombolytic strategies for ischemic stroke in the thrombectomy era. J Thromb Haemost 2021; 19:1618-1628. [PMID: 33834615 DOI: 10.1111/jth.15336] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 02/03/2023]
Abstract
Twenty-five years ago, intravenous thrombolysis has revolutionized the care of patients with acute ischemic stroke. Since 2015, randomized clinical trials have demonstrated that mechanical thrombectomy improves functional outcome in stroke patients over intravenous thrombolysis alone. More recently, three randomized clinical trials have suggested that mechanical thrombectomy alone is noninferior to a combined strategy with both intravenous thrombolysis and mechanical thrombectomy. In the present review, we will present the last clinical and preclinical studies on the use of thrombolysis in stroke patients in the modern thrombectomy era. At the cost of a potential increased risk of hemorrhagic transformation, thrombolysis may promote arterial recanalization before thrombectomy, improve the rate of successful recanalization after thrombectomy, and restore microcirculation patency downstream of the main thrombus. Besides, new thrombolytic strategies targeting tissue-type plasminogen activator resistant thrombi are being developed, which could strengthen the beneficial effects of thrombolysis without carrying additional pro-hemorrhagic effects. For instance, tenecteplase has shown improved rate of recanalization compared with tissue-type plasminogen activator (alteplase). Beyond fibrinolysis, DNA- and von Willebrand factor-targeted thrombolytic strategies have shown promising results in experimental models of ischemic stroke. New combined strategies, improved thrombolytics, and dedicated clinical trials in selected patients are eagerly awaited to further improve functional outcome in stroke.
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Affiliation(s)
- Maxime Gauberti
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
- CHU Caen, Department of Neuroradiology, CHU de Caen Côte de Nacre, Caen, France
| | - Sara Martinez de Lizarrondo
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
| | - Denis Vivien
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
- CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, Caen, France
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Sarraj A, Grotta J, Albers GW, Hassan AE, Blackburn S, Day A, Sitton C, Abraham M, Cai C, Dannenbaum M, Pujara D, Hicks W, Budzik R, Vora N, Arora A, Alenzi B, Tekle WG, Kamal H, Mir O, Barreto AD, Lansberg M, Gupta R, Martin-Schild S, Savitz S, Tsivgoulis G. Clinical and Neuroimaging Outcomes of Direct Thrombectomy vs Bridging Therapy in Large Vessel Occlusion: Analysis of the SELECT Cohort Study. Neurology 2021; 96:e2839-e2853. [PMID: 33875560 PMCID: PMC8205460 DOI: 10.1212/wnl.0000000000012063] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 03/11/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the comparative safety and efficacy of direct endovascular thrombectomy (dEVT) compared to bridging therapy (BT; IV tissue plasminogen activator + EVT) and to assess whether BT potential benefit relates to stroke severity, size, and initial presentation to EVT vs non-EVT center. METHODS In a prospective multicenter cohort study of imaging selection for endovascular thrombectomy (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke [SELECT]), patients with anterior circulation large vessel occlusion (LVO) presenting to EVT-capable centers within 4.5 hours from last known well were stratified into BT vs dEVT. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] score 0-2). Secondary outcomes included a shift across 90-day mRS grades, mortality, and symptomatic intracranial hemorrhage. We also performed subgroup analyses according to initial presentation to EVT-capable center (direct vs transfer), stroke severity, and baseline infarct core volume. RESULTS We identified 226 LVOs (54% men, mean age 65.6 ± 14.6 years, median NIH Stroke Scale [NIHSS] score 17, 28% received dEVT). Median time from arrival to groin puncture did not differ in patients with BT when presenting directly (dEVT 1.43 [interquartile range (IQR) 1.13-1.90] hours vs BT 1.58 [IQR 1.27-2.02] hours, p = 0.40) or transferred to EVT-capable centers (dEVT 1.17 [IQR 0.90-1.48] hours vs BT 1.27 [IQR 0.97-1.87] hours, p = 0.24). BT was associated with higher odds of 90-day functional independence (57% vs 44%, adjusted odds ratio [aOR] 2.02, 95% confidence interval [CI] 1.01-4.03, p = 0.046) and functional improvement (adjusted common OR 2.06, 95% CI 1.18-3.60, p = 0.011) and lower likelihood of 90-day mortality (11% vs 23%, aOR 0.20, 95% CI 0.07-0.58, p = 0.003). No differences in any other outcomes were detected. In subgroup analyses, patients with BT with baseline NIHSS scores <15 had higher functional independence likelihood compared to those with dEVT (aOR 4.87, 95% CI 1.56-15.18, p = 0.006); this association was not evident for patients with NIHSS scores ≥15 (aOR 1.05, 95% CI 0.40-2.74, p = 0.92). Similarly, functional outcomes improvements with BT were detected in patients with core volume strata (ischemic core <50 cm3: aOR 2.10, 95% CI 1.02-4.33, p = 0.044 vs ischemic core ≥50 cm3: aOR 0.41, 95% CI 0.01-16.02, p = 0.64) and transfer status (transferred: aOR 2.21, 95% CI 0.93-9.65, p = 0.29 vs direct to EVT center: aOR 1.84, 95% CI 0.80-4.23, p = 0.15). CONCLUSIONS BT appears to be associated with better clinical outcomes, especially with milder NIHSS scores, smaller presentation core volumes, and those who were "dripped and shipped." We did not observe any potential benefit of BT in patients with more severe strokes. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02446587. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with ischemic stroke from anterior circulation LVO within 4.5 hours from last known well, BT compared to dEVT leads to better 90-day functional outcomes.
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Affiliation(s)
- Amrou Sarraj
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece.
| | - James Grotta
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Gregory W Albers
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Ameer E Hassan
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Spiros Blackburn
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Arthur Day
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Clark Sitton
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Michael Abraham
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Chunyan Cai
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Mark Dannenbaum
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Deep Pujara
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - William Hicks
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Ronald Budzik
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Nirav Vora
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Ashish Arora
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Bader Alenzi
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Wondwossen G Tekle
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Haris Kamal
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Osman Mir
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Andrew D Barreto
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Maarten Lansberg
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Rishi Gupta
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Sheryl Martin-Schild
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Sean Savitz
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Georgios Tsivgoulis
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
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15
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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16
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Arrarte Terreros N, Bruggeman AAE, Swijnenburg ISJ, van Meenen LCC, Groot AE, Coutinho JM, Roos YBWEM, Emmer BJ, Beenen LFM, van Bavel E, Marquering HA, Majoie CBLM. Early recanalization in large-vessel occlusion stroke patients transferred for endovascular treatment. J Neurointerv Surg 2021; 14:neurintsurg-2021-017441. [PMID: 33986112 PMCID: PMC9016237 DOI: 10.1136/neurintsurg-2021-017441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/24/2021] [Accepted: 04/29/2021] [Indexed: 11/25/2022]
Abstract
Background We performed an exploratory analysis to identify patient and thrombus characteristics associated with early recanalization in large-vessel occlusion (LVO) stroke patients transferred for endovascular treatment (EVT) from a primary (PSC) to a comprehensive stroke center (CSC). Methods We included patients with an LVO stroke of the anterior circulation who were transferred to our hospital for EVT and underwent repeated imaging between January 2016 and June 2019. We compared patient characteristics, workflow time metrics, functional outcome (modified Rankin Scale at 90 days), and baseline thrombus imaging characteristics, which included: occlusion location, thrombus length, attenuation, perviousness, distance from terminus of intracranial carotid artery to the thrombus (DT), and clot burden score (CBS), between early-recanalized LVO (ER-LVO), and non-early-recanalized LVO (NER-LVO) patients. Results One hundred and forty-nine patients were included in the analysis. Early recanalization occurred in 32% of patients. ER-LVO patients less often had a medical history of hypertension (31% vs 49%, P=0.04), and more often had clinical improvement between PSC and CSC (ΔNIHSS −5 vs 3, P<0.01), compared with NER-LVO patients. Thrombolysis administration was similar in both groups (88% vs 78%, P=0.18). ER-LVO patients had no ICA occlusions (0% vs 27%, P<0.01), more often an M2 occlusion (35% vs 17%, P=0.01), longer DT (27 mm vs 12 mm, P<0.01), shorter thrombi (17 mm vs 27 mm, P<0.01), and higher CBS (8 vs 6, P<0.01) at baseline imaging. ER-LVO patients had lower mRS scores (1 vs 3, P=0.02). Conclusions Early recanalization is associated with clinical improvement between PSC and CSC admission, more distal occlusions and shorter thrombi at baseline imaging, and better functional outcome.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands .,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Agnetha A E Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Isabella S J Swijnenburg
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Laura C C van Meenen
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Adrien E Groot
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
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17
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Schlemm L, Endres M, Nolte CH. Cost Effectiveness of Interhospital Transfer for Mechanical Thrombectomy of Acute Large Vessel Occlusion Stroke: Role of Predicted Recanalization Rates. Circ Cardiovasc Qual Outcomes 2021; 14:e007444. [PMID: 33813852 DOI: 10.1161/circoutcomes.120.007444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Emergency interhospital transfer of patients with stroke with large vessel occlusion to a comprehensive stroke center for mechanical thrombectomy is resource-intensive and can be logistically challenging. Imaging markers may identify patients in whom intravenous thrombolysis (IVT) alone is likely to result in thrombus resolution, potentially rendering interhospital transfers unnecessary. Here, we investigate how predicted probabilities to achieve IVT-mediated recanalization affect cost-effectiveness estimates of interhospital transfer. METHODS We performed a health economic analysis comparing emergency interhospital transfer of patients with acute large vessel occlusion stroke after administration of IVT with a scenario in which patients also receive IVT but remain at the primary hospital. Results were stratified by clinical parameters, treatment delays, and the predicted probability to achieve IVT-mediated recanalization. Estimated 3-month outcomes were combined with a long-term probabilistic model to yield quality-adjusted life years (QALYs) and costs. Uncertainty was quantified in probabilistic sensitivity analyses. RESULTS Depending on input parameters, marginal costs of interhospital transfer ranged from USD -61 366 (cost saving) to USD +20 443 and additional QALYs gained from 0.1 to 3.0, yielding incremental cost-effectiveness ratios of <USD 0 (dominant) to USD 310 000 per QALY. For some elderly patients with moderate or severe stroke symptoms treated in a remote primary stroke center, transfer was unlikely to be cost effective at a willingness-to-pay threshold of USD 100 000 and 50 000 per QALY (20% and 1%, respectively) if the predicted probability to achieve IVT-related recanalization was high. On the other hand, in some younger patients, the analysis yielded incremental cost-effectiveness ratio estimates below USD 20 000 per QALY independent of the predicted recanalization rate. CONCLUSIONS Predicted probabilities to achieve IVT-mediated recanalization significantly affect the cost-effectiveness of interhospital transfer for MT, in particular in elderly patients with moderate or severe stroke symptoms. However, high predicted recanalization rates alone do not generally imply that patients should not be considered for transfer.
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Affiliation(s)
- Ludwig Schlemm
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.).,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany (L.S., M.E., C.H.N.).,Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.)
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.).,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany (L.S., M.E., C.H.N.).,Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.).,DZHK (German Center for Cardiovascular Research) (M.E., C.H.N.), Partner Site Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases) (M.E., C.H.N.), Partner Site Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.).,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany (L.S., M.E., C.H.N.).,Berlin Institute of Health (BIH), Germany (L.S., M.E., C.H.N.).,DZHK (German Center for Cardiovascular Research) (M.E., C.H.N.), Partner Site Berlin, Germany.,DZNE (German Center for Neurodegenerative Diseases) (M.E., C.H.N.), Partner Site Berlin, Germany
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18
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Seners P, Ben Hassen W, Lapergue B, Arquizan C, Heldner MR, Henon H, Perrin C, Strambo D, Cottier JP, Sablot D, Girard Buttaz I, Tamazyan R, Preterre C, Agius P, Laksiri N, Mechtouff L, Béjot Y, Duong DL, Mounier-Vehier F, Mione G, Rosso C, Lucas L, Papassin J, Aignatoaie A, Triquenot A, Carrera E, Niclot P, Obadia A, Lyoubi A, Garnier P, Crainic N, Wolff V, Tracol C, Philippeau F, Lamy C, Soize S, Baron JC, Turc G. Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone. JAMA Neurol 2021; 78:321-328. [PMID: 33427887 DOI: 10.1001/jamaneurol.2020.4557] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance The best reperfusion strategy in patients with acute minor stroke and large vessel occlusion (LVO) is unknown. Accurately predicting early neurological deterioration of presumed ischemic origin (ENDi) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy. Objective To develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke and LVO. Design, Setting, and Participants This multicentric retrospective cohort included 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score of 5 or less) and LVO (basilar artery, internal carotid artery, first [M1] or second [M2] segment of middle cerebral artery) intended for IVT alone in 45 French stroke centers, ie, including those who eventually received rescue thrombectomy because of ENDi. For external validation, another cohort of 347 patients with similar inclusion criteria was collected from 9 additional centers. Data were collected from January 2018 to September 2019. Main Outcomes and Measures ENDi, defined as 4 or more points' deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause. Results Of the 729 patients in the derivation cohort, 335 (46.0%) were male, and the mean (SD) age was 70 (15) years; of the 347 patients in the validation cohort, 190 (54.8%) were male, and the mean (SD) age was 69 (15) years. In the derivation cohort, the median (interquartile range) NIHSS score was 3 (1-4), and the occlusion site was the internal carotid artery in 97 patients (13.3%), M1 in 207 (28.4%), M2 in 395 (54.2%), and basilar artery in 30 (4.1%). ENDi occurred in 88 patients (12.1%; 95% CI, 9.7-14.4) and was strongly associated with poorer 3-month outcomes, even in patients who underwent rescue thrombectomy. In multivariable analysis, a more proximal occlusion site and a longer thrombus were independently associated with ENDi. A 4-point score derived from these variables-1 point for thrombus length and 3 points for occlusion site-showed good discriminative power for ENDi (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (ENDi rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, ENDi probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively. Conclusions and Relevance The substantial ENDi rates observed in these cohorts highlights the current debate regarding whether to directly transfer patients with IVT-treated minor stroke and LVO for additional thrombectomy. Based on the strong associations observed, an easily applicable score for ENDi risk prediction that may assist decision-making was derived and externally validated.
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Affiliation(s)
- Pierre Seners
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Wagih Ben Hassen
- Radiology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | | | | | - Mirjam R Heldner
- Neurology Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Hilde Henon
- Neurology Department, CHU Lille, Université de Lille, INSERM U1171, Lille, France
| | - Claire Perrin
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Davide Strambo
- Stroke Center, Neurology Service, CHU Vaudois, Lausanne University, Lausanne, Switzerland
| | | | - Denis Sablot
- Neurology Department, Perpignan Hospital, Perpignan, France
| | | | - Ruben Tamazyan
- Neurology Department, Saint Joseph Hospital, Paris, France
| | - Cécile Preterre
- Neurology Department, Nantes University Hospital, Nantes, France
| | - Pierre Agius
- Neurology Department, Nantes University Hospital, Nantes, France.,Neurology Department, St Nazaire Hospital, Saint-Nazaire, France
| | - Nadia Laksiri
- Neurology Department, La Timone University Hospital, Marseille, France
| | - Laura Mechtouff
- Department of Stroke Medicine, Hospices Civils de Lyon, Lyon, France
| | - Yannick Béjot
- Neurology Department, Dijon University Hospital, Dijon, France
| | - Duc-Long Duong
- Neurology Department, Versailles University Hospital, Versailles, France
| | | | - Gioia Mione
- Neurology Department, Nancy University Hospital, Nancy, France
| | - Charlotte Rosso
- Sorbonne Université, Institut du Cerveau et de la Moelle épinière, ICM, INSERM U 1127, CNRS UMR 7225, AP-HP, Urgences Cérébro-Vasculaires, ICM Infrastructure Stroke Network, Hôpital Pitié-Salpêtrière, Paris, France
| | - Ludovic Lucas
- Stroke Unit, Bordeaux University Hospital, Bordeaux, France
| | - Jérémie Papassin
- Stroke Unit, Grenoble University Hospital, Grenoble, France.,Neurology Department, Centre Hospitalier Metropole-Savoie, Chambery, France
| | - Andreea Aignatoaie
- Neurology Department, Centre Hospitalier Régional d'Orléans, Orléans, France
| | | | - Emmanuel Carrera
- Neurology Department, Geneve University Hospital, Geneve, Switzerland
| | | | - Alexandre Obadia
- Neurology Department, Fondation Adolphe de Rothschild, Paris, France
| | - Aïcha Lyoubi
- Neurology Department, Delafontaine Hospital, Saint-Denis, France
| | - Pierre Garnier
- Stroke Unit, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Nicolae Crainic
- Neurology Department, Brest University Hospital, Brest, France
| | - Valérie Wolff
- Neurology Department, Strasbourg University Hospital, Strasbourg, France
| | - Clément Tracol
- Neurology Department, Rennes University Hospital, Rennes, France
| | | | - Chantal Lamy
- Neurology Department, Amiens University Hospital, Amiens, France
| | - Sébastien Soize
- Neuroradiology Department, Reims University Hospital, Reims, France
| | - Jean-Claude Baron
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Guillaume Turc
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
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19
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Wu X, Khunte M, Payabvash S, Zhu C, Brackett A, Matouk CC, Gandhi D, Sanelli P, Malhotra A. Outcomes after Thrombectomy for Minor Stroke: A Meta-Analysis. World Neurosurg 2020; 149:e1140-e1154. [PMID: 33359881 DOI: 10.1016/j.wneu.2020.12.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the outcomes after mechanical thrombectomy (MT) versus medical management in patients with minor stroke symptomatology. METHODS A meta-analysis was performed for studies reporting outcomes after MT, either as stand-alone therapy or with intravenous thrombolysis in patients with minor stroke and large-vessel occlusion. RESULTS Fourteen studies with 2134 patients met the selection criteria and were included. Two studies compared immediate thrombectomy versus best medical management (with rescue thrombectomy) and the odds ratios of excellent outcomes, good outcomes, mortality and incidence of symptomatic intracranial hemorrhage (sICH) after immediate thrombectomy versus best medical management were 1.07 (95% confidence interval [CI] 0.93-1.22%), 1.15 (95% CI 1.05-1.25), 0.65 (95% CI 0.30-1.38), and 2.89 (95% CI 0.82-10.13), respectively. Among the 8 studies that compared MT outcomes versus medical management (without thrombectomy), odds ratios of excellent outcomes, good outcomes, mortality, and incidence of sICH after MT versus medical management were 0.98 (95% CI 0.89-1.07), 0.94 (95% CI 0.89-1.00), 1.61 (95% CI 1.08-2.41), and 2.59 (95% CI 1.35-4.96), respectively. Among all 14 studies, pooled proportions of excellent outcomes, good outcomes, mortality, and sICH after thrombectomy were 58.7%, 76.2%, 6.82%, and 3.23%, respectively. CONCLUSIONS Our study shows significant selection bias and heterogeneity in the literature with differences in baseline characteristics (age, stroke severity, prestroke modified Rankin Scale score, side of infarct, vessel and site of occlusion, use of intravenous thrombolysis, criteria for clinical deterioration, and selection bias for rescue MT and rates of reperfusion), emphasizing the need for a randomized controlled trial.
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Affiliation(s)
- Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sam Payabvash
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chengcheng Zhu
- Department of Radiology and Biomedical Imaging, University of Washington, Seattle, Washington, USA
| | - Alexandria Brackett
- Clinical Information Services, Yale School of Medicine, New Haven, Connecticut, USA
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Dheeraj Gandhi
- Interventional Neuroradiology Nuclear Medicine, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Pina Sanelli
- Department of Radiology, Northwell Health Imaging Clinical Effectiveness and Outcomes Research (iCEOR) Program, Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA.
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20
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Seners P, Perrin C, Lapergue B, Henon H, Debiais S, Sablot D, Girard Buttaz I, Tamazyan R, Preterre C, Laksiri N, Mione G, Arquizan C, Lucas L, Baron JC, Turc G. Bridging Therapy or IV Thrombolysis in Minor Stroke with Large Vessel Occlusion. Ann Neurol 2020; 88:160-169. [PMID: 32350929 DOI: 10.1002/ana.25756] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/08/2020] [Accepted: 04/12/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Whether bridging therapy (intravenous thrombolysis [IVT] followed by endovascular treatment) is superior to IVT alone in minor stroke with large vessel occlusion (LVO) is unknown. METHODS Multicentric retrospective observational study including, in intention-to-treat, consecutive IVT-treated minor strokes (National Institutes of Health Stroke Scale [NIHSS] ≤ 5) with LVO, with or without additional mechanical thrombectomy. Propensity-score (inverse probability of treatment weighting) was used to reduce baseline between-groups differences. The primary outcome was excellent outcome, that is, modified Rankin score 0 to 1 at 3 months follow-up. RESULTS Overall, 598 patients were included (214 and 384 in the bridging therapy and IVT groups, respectively). Following propensity-score weighting, the distribution of baseline clinical and radiological variables was similar across the two patient groups. Compared with IVT alone, bridging therapy was not associated with excellent outcome (odds ratio [OR] = 0.96; 95% confidence interval [CI] = 0.75-1.24; p = 0.76), but was associated with symptomatic intracranial hemorrhage (OR = 3.01; 95% CI = 1.77-5.11; p < 0.0001). Occlusion site was a strong modifier of the effect of bridging therapy on outcome (pinteraction < 0.0001), with bridging therapy associated with higher odds of excellent outcome in proximal M1 (OR = 3.26; 95% CI = 1.67-6.35; p = 0.0006) and distal M1 (OR = 1.69; 95% CI = 1.01-2.82; p = 0.04) occlusions, but with lower odds of excellent outcome for M2 (OR = 0.53; 95% CI = 0.38-0.75; p = 0.0003) occlusions. Bridging therapy was associated with higher rates of symptomatic intracranial hemorrhage in M2 occlusions only (OR = 4.40; 95% CI = 2.20-8.83; p < 0.0001). INTERPRETATION Although overall outcomes were similar in intended bridging therapy as compared to intended IVT alone in minor strokes with LVO, our results suggest that intended bridging therapy may be beneficial in M1 occlusions, whereas the benefit-risk profile may favor IVT alone in M2 occlusions. ANN NEUROL 2020 ANN NEUROL 2020;88:160-169.
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Affiliation(s)
- Pierre Seners
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Université de Paris, FHU NeuroVasc, Institute of Psychiatrie and Neuroscience of Paris (IPNP), INSERM UMR 1266, Paris, France
| | - Claire Perrin
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Université de Paris, FHU NeuroVasc, Institute of Psychiatrie and Neuroscience of Paris (IPNP), INSERM UMR 1266, Paris, France
| | | | - Hilde Henon
- Department of Neurology, Université de Lille, INSERM UMR 1171, CHU Lille, Lille, France
| | | | - Denis Sablot
- Neurology Department, Perpignan Hospital, Perpignan, France
| | | | - Ruben Tamazyan
- Neurology Department, Saint Joseph Hospital, Paris, France
| | - Cécile Preterre
- Neurology Department, Nantes University Hospital, Nantes, France
| | - Nadia Laksiri
- Neurology Department, La Timone University Hospital, Marseille, France
| | - Gioia Mione
- Neurology Department, Nancy University Hospital, Nancy, France
| | | | - Ludovic Lucas
- Stroke Unit, Pellegrin University Hospital, Bordeaux, France
| | - Jean-Claude Baron
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Université de Paris, FHU NeuroVasc, Institute of Psychiatrie and Neuroscience of Paris (IPNP), INSERM UMR 1266, Paris, France
| | - Guillaume Turc
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Université de Paris, FHU NeuroVasc, Institute of Psychiatrie and Neuroscience of Paris (IPNP), INSERM UMR 1266, Paris, France
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21
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Tsivgoulis G, Goyal N, Katsanos AH, Malhotra K, Ishfaq MF, Pandhi A, Frohler MT, Spiotta AM, Anadani M, Psychogios M, Maus V, Siddiqui A, Waqas M, Schellinger PD, Groen M, Krogias C, Richter D, Saqqur M, Garcia-Bermejo P, Mokin M, Leker R, Cohen JE, Magoufis G, Psychogios K, Lioutas VA, Van Nostrand M, Sharma VK, Paciaroni M, Rentzos A, Shoirah H, Mocco J, Nickele C, Mitsias PD, Inoa V, Hoit D, Elijovich L, Arthur AS, Alexandrov AV. Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity. Eur J Neurol 2020; 27:1039-1047. [PMID: 32149450 DOI: 10.1111/ene.14199] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 02/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. METHODS The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. RESULTS We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. CONCLUSIONS Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.
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Affiliation(s)
- G Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - N Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - K Malhotra
- Charleston Division, Department of Neurology, West Virginia University, Charleston, WV, USA
| | - M F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - A Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M T Frohler
- Cerebrovascular Program, Vanderbilt University, Nashville, TN, USA
| | - A M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - V Maus
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - A Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - M Waqas
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - P D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - M Groen
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - C Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - D Richter
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - M Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Neurology, Hamad General Hospital, Doha, Qatar
| | - P Garcia-Bermejo
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Magoufis
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - K Psychogios
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - V A Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - M Van Nostrand
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - V K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, National University Hospital, Singapore, Singapore
| | - M Paciaroni
- Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy
| | - A Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - H Shoirah
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - C Nickele
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - P D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.,Department of Neurology, School of Medicine, University of Crete, Herakleion, Greece
| | - V Inoa
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - D Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - L Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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22
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Yu Y, Xie Y, Thamm T, Gong E, Ouyang J, Huang C, Christensen S, Marks MP, Lansberg MG, Albers GW, Zaharchuk G. Use of Deep Learning to Predict Final Ischemic Stroke Lesions From Initial Magnetic Resonance Imaging. JAMA Netw Open 2020; 3:e200772. [PMID: 32163165 PMCID: PMC7068232 DOI: 10.1001/jamanetworkopen.2020.0772] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Predicting infarct size and location is important for decision-making and prognosis in patients with acute stroke. OBJECTIVES To determine whether a deep learning model can predict final infarct lesions using magnetic resonance images (MRIs) acquired at initial presentation (baseline) and to compare the model with current clinical prediction methods. DESIGN, SETTING, AND PARTICIPANTS In this multicenter prognostic study, a specific type of neural network for image segmentation (U-net) was trained, validated, and tested using patients from the Imaging Collaterals in Acute Stroke (iCAS) study from April 14, 2014, to April 15, 2018, and the Diffusion Weighted Imaging Evaluation for Understanding Stroke Evolution Study-2 (DEFUSE-2) study from July 14, 2008, to September 17, 2011 (reported in October 2012). Patients underwent baseline perfusion-weighted and diffusion-weighted imaging and MRI at 3 to 7 days after baseline. Patients were grouped into unknown, minimal, partial, and major reperfusion status based on 24-hour imaging results. Baseline images acquired at presentation were inputs, and the final true infarct lesion at 3 to 7 days was considered the ground truth for the model. The model calculated the probability of infarction for every voxel, which can be thresholded to produce a prediction. Data were analyzed from July 1, 2018, to March 7, 2019. MAIN OUTCOMES AND MEASURES Area under the curve, Dice score coefficient (DSC) (a metric from 0-1 indicating the extent of overlap between the prediction and the ground truth; a DSC of ≥0.5 represents significant overlap), and volume error. Current clinical methods were compared with model performance in subgroups of patients with minimal or major reperfusion. RESULTS Among the 182 patients included in the model (97 women [53.3%]; mean [SD] age, 65 [16] years), the deep learning model achieved a median area under the curve of 0.92 (interquartile range [IQR], 0.87-0.96), DSC of 0.53 (IQR, 0.31-0.68), and volume error of 9 (IQR, -14 to 29) mL. In subgroups with minimal (DSC, 0.58 [IQR, 0.31-0.67] vs 0.55 [IQR, 0.40-0.65]; P = .37) or major (DSC, 0.48 [IQR, 0.29-0.65] vs 0.45 [IQR, 0.15-0.54]; P = .002) reperfusion for which comparison with existing clinical methods was possible, the deep learning model had comparable or better performance. CONCLUSIONS AND RELEVANCE The deep learning model appears to have successfully predicted infarct lesions from baseline imaging without reperfusion information and achieved comparable performance to existing clinical methods. Predicting the subacute infarct lesion may help clinicians prepare for decompression treatment and aid in patient selection for neuroprotective clinical trials.
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Affiliation(s)
- Yannan Yu
- Department of Radiology, Stanford University, Stanford, California
| | - Yuan Xie
- Department of Radiology, Stanford University, Stanford, California
| | - Thoralf Thamm
- Department of Radiology, Stanford University, Stanford, California
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Enhao Gong
- Department of Electrical Engineering, Stanford University, Stanford, California
| | - Jiahong Ouyang
- Department of Electrical Engineering, Stanford University, Stanford, California
| | - Charles Huang
- Department of Electrical Engineering, Stanford University, Stanford, California
| | | | - Michael P. Marks
- Department of Radiology, Stanford University, Stanford, California
| | | | | | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, California
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23
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Li G, Wu G, Qin Z, Li H, Cheng X, Cai Y. Prognostic Value of Clot Burden Score in Acute Ischemic Stroke after Reperfusion Therapies: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2019; 28:104293. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/12/2019] [Accepted: 07/10/2019] [Indexed: 01/08/2023] Open
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Abstract
Patient-level health outcomes for acute ischemic stroke have significantly improved in the last decade primarily because of superior overall case management, availability of tailored drug interventions, and advances in endovascular procedures. Nevertheless, disease registries show a "quality gap" across social determinants of health and between in-hospital and community-onset strokes. Several factors, including financing and infrastructure constraints, limited expertise, and clinical uncertainty, still prevent adherence to evidence-based clinical guidelines and optimal care pathways. This paper critically appraises existing evidence on the use of drug therapies in acute ischemic stroke, in an attempt to resolve physician-related subjective barriers for effective acute management of the disease. We conclude that intravenous administration of rt-PA (recombinant tissue-type plasminogen activator, alteplase) is an essential component of acute-phase pharmacologic treatment and a driver for the improvement of overall ischemic stroke health outcomes. The safety profile of alteplase and similar treatments are well within the patient benefit zone of eligible patients when compared to non-treatment alternatives. Monomodal neuroprotective drugs with single or pleiotropic mechanisms of action have failed to support long-term sustainable results. Drugs with complex mechanisms of action that promote neurorecovery, such as cerebrolysin, are valid options for adjunctive treatment of acute ischemic stroke. Recent years have shown clear improvements in the methodology and design of clinical trials, with an increase in overall internal and external validity. A better understanding of study limitations has not hindered, but enhanced their potential to contribute, together with sometimes superior data sources, to health decision making.
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Affiliation(s)
- Dafin F Muresanu
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364, Cluj-Napoca, Romania
| | - Stefan Strilciuc
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012, Cluj-Napoca, Romania.
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364, Cluj-Napoca, Romania.
| | - Adina Stan
- Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, No. 8 Victor Babes Street, 400012, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400364, Cluj-Napoca, Romania
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