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Klein P, Huo X, Chen Y, Abdalkader M, Qiu Z, Nagel S, Raymond J, Liu L, Siegler JE, Strbian D, Field TS, Yaghi S, Qureshi MM, Demeestere J, Puetz V, Berberich A, Michel P, Fischer U, Kaesmacher J, Yamagami H, Alemseged F, Tsivgoulis G, Schonewille WJ, Hu W, Liu X, Li C, Ji X, Drumm B, Banerjee S, Sacco S, Sandset EC, Kristoffersen ES, Slade P, Mikulik R, Romoli M, Diana F, Krishnan K, Dhillon P, Lee JS, Kasper E, Dasenbrock H, Ton MD, Masiliūnas R, Arsovska AA, Marto JP, Dmytriw AA, Regenhardt RW, Silva GS, Siepmann T, Sun D, Sang H, Diestro JD, Yang P, Mohammaden MH, Li F, Masoud HE, Ma A, Raynald, Ganesh A, Liu J, Meyer L, Dippel DWJ, Thomalla G, Parsons M, Qureshi AI, Goyal M, Yoo AJ, Lapergue B, Zaidat OO, Chen HS, Campbell BCV, Jovin TG, Nogueira RG, Miao Z, Saposnik G, Nguyen TN. Specialist Perspectives on the Imaging Selection of Large Vessel Occlusion in the Late Window. Clin Neuroradiol 2023; 33:801-811. [PMID: 37010551 PMCID: PMC10069362 DOI: 10.1007/s00062-023-01284-0] [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: 01/04/2023] [Accepted: 02/23/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND The proper imaging modality for use in the selection of patients for endovascular thrombectomy (EVT) presenting in the late window remains controversial, despite current guidelines advocating the use of advanced imaging in this population. We sought to understand if clinicians with different specialty training differ in their approach to patient selection for EVT in the late time window. METHODS We conducted an international survey of stroke and neurointerventional clinicians between January and May 2022 with questions focusing on imaging and treatment decisions of large vessel occlusion (LVO) patients presenting in the late window. Interventional neurologists, interventional neuroradiologists, and endovascular neurosurgeons were defined as interventionists whereas all other specialties were defined as non-interventionists. The non-interventionist group was defined by all other specialties of the respondents: stroke neurologist, neuroradiologist, emergency medicine physician, trainee (fellows and residents) and others. RESULTS Of 3000 invited to participate, 1506 (1027 non-interventionists, 478 interventionists, 1 declined to specify) physicians completed the study. Interventionist respondents were more likely to proceed directly to EVT (39.5% vs. 19.5%; p < 0.0001) compared to non-interventionist respondents in patients with favorable ASPECTS (Alberta Stroke Program Early CT Score). Despite no difference in access to advanced imaging, interventionists were more likely to prefer CT/CTA alone (34.8% vs. 21.0%) and less likely to prefer CT/CTA/CTP (39.1% vs. 52.4%) for patient selection (p < 0.0001). When faced with uncertainty, non-interventionists were more likely to follow clinical guidelines (45.1% vs. 30.2%) while interventionists were more likely to follow their assessment of evidence (38.7% vs. 27.0%) (p < 0.0001). CONCLUSION Interventionists were less likely to use advanced imaging techniques in selecting LVO patients presenting in the late window and more likely to base their decisions on their assessment of evidence rather than published guidelines. These results reflect gaps between interventionists and non-interventionists reliance on clinical guidelines, the limits of available evidence, and clinician belief in the utility of advanced imaging.
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Affiliation(s)
- Piers Klein
- Neurology, Boston Medical Center, Boston, USA
- Radiology, Boston Medical Center, Boston, USA
| | - Xiaochuan Huo
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Yimin Chen
- Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Mohamad Abdalkader
- Radiology, Boston Medical Center, Boston, USA
- Neurology, St. Elizabeth's Medical Center, Boston, USA
| | - Zhongming Qiu
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Simon Nagel
- Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
- Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jean Raymond
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada
| | - Liping Liu
- Neurology, Beijing Tiantan Hospital, Beijing, China
| | | | - Daniel Strbian
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Thalia S Field
- Neurology, University of British Columbia, Vancouver, Canada
| | - Shadi Yaghi
- Neurology, Rhode Island Hospital, Providence, USA
| | | | | | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | | | - Patrik Michel
- Stroke Center/Neurology, Lausanne University Hospital, Lausanne, Switzerland
| | - Urs Fischer
- Neurology, Basel University Hospital, Basel, Switzerland
| | - Johannes Kaesmacher
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | | | | | | | | | - Wei Hu
- Stroke Center, The First Affiliated Hospital of USTC, Hefei, China
| | - Xinfeng Liu
- Stroke Center, The First Affiliated Hospital of USTC, Hefei, China
| | | | - Xunming Ji
- Neurosurgery, Xuanwu Hospital, Beijing, China
| | - Brian Drumm
- Stroke Medicine, Imperial College Healthcare, London, UK
| | - Soma Banerjee
- Stroke Medicine, Imperial College Healthcare, London, UK
| | - Simona Sacco
- Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | | | - Peter Slade
- Morriston Hospital, Swansea Hospital, Swansea, Wales, UK
| | - Robert Mikulik
- Neurology, St Anne's University Hospital, Brno, Czech Republic
| | | | - Francesco Diana
- Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Kailash Krishnan
- Stroke, Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Permesh Dhillon
- Interventional Neuroradiology, Nottingham University Hospitals, Nottingham, UK
| | - Jin Soo Lee
- Neurology, Ajou University Hospital, Suwon, Korea (Republic of)
| | - Ekkehard Kasper
- Neurosurgery, Boston Medical Center, Boston, USA
- Neurosurgery, St. Elizabeth's Medical Center, Boston, USA
| | - Hormuzdiyar Dasenbrock
- Neurosurgery, Boston Medical Center, Boston, USA
- Neurosurgery, St. Elizabeth's Medical Center, Boston, USA
| | - Mai Duy Ton
- Stroke Center, Bach Mai Hospital, Hanoi, Viet Nam
- Neurology, Vietnam National University of Medicine and Pharmacy, Hanoi, Vietnam
| | | | | | | | - Adam A Dmytriw
- Neurointerventional, London Health Sciences Centre, London, Canada
- Neuroendovascular, Massachusetts General Hospital, Boston, USA
| | | | - Gisele Sampaio Silva
- Universidade Federal de São Paulo (UNIFESP) and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Dapeng Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Hongfei Sang
- Neurology, Affiliated Hangzhou First People's Hospital, Hangzhou, China
| | - Jose Danilo Diestro
- Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Pengfei Yang
- Neurosurgery, Changhai Hospital, Shanghai, China
| | | | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | | | - Alice Ma
- Royal North Shore Hospital, Sydney, Australia
| | - Raynald
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | | - Jianmin Liu
- Neurosurgery, Changhai Hospital, Shanghai, China
| | - Lukas Meyer
- Interventionelle Neuroradiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Götz Thomalla
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Mark Parsons
- South Western Sydney Clinical School, Liverpool Hospital, Liverpool, Australia
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, USA
| | - Mayank Goyal
- Radiology, University of Calgary, Calgary, Canada
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, USA
| | | | - Osama O Zaidat
- Neuroscience, Mercy Health St Vincent Hospital, Toledo, OH, USA
| | - Hui-Sheng Chen
- Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Bruce C V Campbell
- Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | | | - Raul G Nogueira
- Neurology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Gustavo Saposnik
- Stroke Outcomes and Decision Neuroscience Research Unit, University of Toronto, Toronto, Canada
| | - Thanh N Nguyen
- Neurology, Boston Medical Center, Boston, USA.
- Radiology, Boston Medical Center, Boston, USA.
- Neurology, St. Elizabeth's Medical Center, Boston, USA.
- Neurosurgery, Boston Medical Center, Boston, USA.
- Boston University Chobanian and Avedisian School of Medicine, Boston Medical Center, 85 East Concord Street, 02118, Boston, MA, USA.
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Nguyen TN, Qureshi MM, Strambo D, Strbian D, Räty S, Herweh C, Abdalkader M, Olive-Gadea M, Ribo M, Psychogios M, Fischer U, Nguyen A, Kuramatsu JB, Haupenthal D, Köhrmann M, Deuschl C, Kühne Escola J, Yaghi S, Shu L, Puetz V, Kaiser DPO, Kaesmacher J, Mujanovic A, Marterstock DC, Engelhorn T, Klein P, Haussen DC, Mohammaden MH, Abdelhamid H, Souza Viana L, Cunha B, Fragata I, Romoli M, Diana F, Virtanen P, Lappalainen K, Clark J, Matsoukas S, Fifi JT, Sheth SA, Salazar-Marioni S, Marto JP, Ramos JN, Miszczuk M, Riegler C, Jadhav AP, Desai SM, Maus V, Kaeder M, Siddiqui AH, Monteiro A, Masoud HE, Suryadevara N, Mokin M, Thanki S, Siegler JE, Khalife J, Linfante I, Dabus G, Asdaghi N, Saini V, Nolte CH, Siebert E, Meinel TR, Finitsis S, Möhlenbruch MA, Ringleb PA, Berberich A, Nogueira RG, Hanning U, Meyer L, Michel P, Nagel S. Endovascular Versus Medical Management of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study. Stroke 2023. [PMID: 37222709 DOI: 10.1161/strokeaha.123.042674] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. METHODS This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. RESULTS Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). CONCLUSIONS In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.
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Affiliation(s)
- Thanh N Nguyen
- Neurology, Boston Medical Center, MA. (T.N.N., J.C.)
- Radiology, Boston Medical Center, MA. (T.N.N., M.M.Q., M.A., P.K.)
| | - Muhammad M Qureshi
- Radiology, Boston Medical Center, MA. (T.N.N., M.M.Q., M.A., P.K.)
- Radiation Oncology, Boston Medical Center, MA. (M.M.Q.)
| | - Davide Strambo
- Neurology Service, Lausanne University Hospital, University of Lausanne, Switzerland (D. Strambo, P.M.)
| | - Daniel Strbian
- Neurology, Helsinki University Hospital, Finland. (D. Strbian, S.R.)
| | - Silja Räty
- Neurology, Helsinki University Hospital, Finland. (D. Strbian, S.R.)
| | - Christian Herweh
- Neuroradiology, Heidelberg University Hospital, Germany. (C.H., M. Moehlenbruch)
| | | | - Marta Olive-Gadea
- Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain. (M.O.-G., M. Ribo)
| | - Marc Ribo
- Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain. (M.O.-G., M. Ribo)
| | - Marios Psychogios
- Neurology Service, Lausanne University Hospital, University of Lausanne, Switzerland (D. Strambo, P.M.)
| | - Urs Fischer
- Neurology, Basel University Hospital, University of Basel, Switzerland. (U.F.)
- Neurology, Bern University Hospital, University of Bern, Switzerland (T.R.M., U.F.)
| | - Anh Nguyen
- Radiology, Basel University Hospital, University of Basel, Switzerland. (A.N, M.P.)
| | - Joji B Kuramatsu
- Neurology, University of Erlangen-Nuremberg, Germany. (J.B.K., D.H.)
| | - David Haupenthal
- Neurology, University of Erlangen-Nuremberg, Germany. (J.B.K., D.H.)
| | - Martin Köhrmann
- Neurology, Universitätsklinikum Essen, Germany. (M. Köhrmann, J.K.E.)
| | | | | | - Shadi Yaghi
- Neurology, Rhode Island Hospital, Brown University Medical School, Providence, RI (S.Y., L.S.)
| | - Liqi Shu
- Neurology, Rhode Island Hospital, Brown University Medical School, Providence, RI (S.Y., L.S.)
| | - Volker Puetz
- Radiology, Helsinki University Hospital, Finland. (P.V., K.L.)
- Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany. (V.P.)
| | - Daniel P O Kaiser
- Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany. (D.P.O.K.)
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Switzerland (J. Kaesmacher, A. Mujanovic)
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Switzerland (J. Kaesmacher, A. Mujanovic)
| | | | - Tobias Engelhorn
- Neuroradiology, University of Erlangen-Nuremberg, Germany. (D.C.M., T.E.)
| | - Piers Klein
- Radiology, Boston Medical Center, MA. (T.N.N., M.M.Q., M.A., P.K.)
| | - Diogo C Haussen
- Neurology, Grady Memorial Hospital, Atlanta, GA (D.C.H., M.H.M., H.A., L.S.V.)
| | | | - Hend Abdelhamid
- Neurology, Grady Memorial Hospital, Atlanta, GA (D.C.H., M.H.M., H.A., L.S.V.)
| | - Lorena Souza Viana
- Neurology, Grady Memorial Hospital, Atlanta, GA (D.C.H., M.H.M., H.A., L.S.V.)
| | - Bruno Cunha
- Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Portugal (B.C., I.F.)
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Portugal (B.C., I.F.)
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli)
| | - Francesco Diana
- Interventional Neuroradiology, Hospital Universitario Vall d'Hebron, Barcelona, Spain. (F.D.)
| | - Pekka Virtanen
- Radiology, Helsinki University Hospital, University of Helsinki, Finland (P.V., K.L.)
| | - Kimmo Lappalainen
- Radiology, Helsinki University Hospital, Finland. (P.V., K.L.)
- Radiology, Helsinki University Hospital, University of Helsinki, Finland (P.V., K.L.)
| | - Judith Clark
- Neurology, Boston Medical Center, MA. (T.N.N., J.C.)
| | - Stavros Matsoukas
- Neurosurgery, Mount Sinai Health System, New York City, NY (S.M., J.T.F.)
| | - Johanna T Fifi
- Neurosurgery, Mount Sinai Health System, New York City, NY (S.M., J.T.F.)
| | - Sunil A Sheth
- Neurology, McGovern Medical School at UTHealth, TX (S.A.S., S.S.-M.)
| | | | - João Pedro Marto
- Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal. (J.P.M.)
| | - João Nuno Ramos
- Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal. (J.N.R.)
| | - Milena Miszczuk
- Neuroradiology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Germany. (M. Miszczuk, E.S.)
| | - Christoph Riegler
- Neurology, Experimental Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Germany. (C.R., C.H.N.)
| | - Ashutosh P Jadhav
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J., S.M.D.)
| | - Shashvat M Desai
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J., S.M.D.)
| | - Volker Maus
- Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany (V.M., M. Kaeder)
| | - Maximilian Kaeder
- Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany (V.M., M. Kaeder)
| | | | - Andre Monteiro
- Neurosurgery, University of Buffalo, NY (A.H.S., A. Monteiro)
| | - Hesham E Masoud
- Neurology, New York Upstate Medical University, Syracuse, NY (H.E.M.)
| | | | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa (M. Mokin, S.T.)
| | - Shail Thanki
- Neurosurgery, University of South Florida, Tampa (M. Mokin, S.T.)
| | - James E Siegler
- Cooper Neurological Institute, Camden, NJ (J.E.S., J. Khalife)
| | - Jane Khalife
- Cooper Neurological Institute, Camden, NJ (J.E.S., J. Khalife)
| | | | | | - Negar Asdaghi
- Neurology, University of Miami Miller School of Medicine, FL (N.A., V.S.)
| | - Vasu Saini
- Neurology, University of Miami Miller School of Medicine, FL (N.A., V.S.)
| | - Christian H Nolte
- Neurology, Experimental Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Germany. (C.R., C.H.N.)
| | - Eberhard Siebert
- Neuroradiology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Germany. (M. Miszczuk, E.S.)
| | - Thomas R Meinel
- Neurology, Bern University Hospital, University of Bern, Switzerland (T.R.M., U.F.)
| | | | - Markus A Möhlenbruch
- Neuroradiology, Heidelberg University Hospital, Germany. (C.H., M. Moehlenbruch)
| | - Peter A Ringleb
- Neurology, Heidelberg University Hospital, Germany. (P.A.R., S.N.)
| | | | - Raul G Nogueira
- Neurology, University of Pittsburgh Medical Center, PA (R.G.N., N.S.)
| | - Uta Hanning
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (U.H., L.M.)
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (U.H., L.M.)
| | - Patrik Michel
- Radiology, Basel University Hospital, University of Basel, Switzerland. (A.N, M.P.)
| | - Simon Nagel
- Neurology, Heidelberg University Hospital, Germany. (P.A.R., S.N.)
- Neurology, University of Pittsburgh Medical Center, PA (R.G.N., N.S.)
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Finitsis S, Berberich A, Nguyen TN, Nagel S. Response to Zhu and Wu's comment on "Endovascular therapy versus no endovascular therapy in patients receiving best medical management for acute isolated occlusion of the posterior cerebral artery: A systematic review and meta-analysis". Eur J Neurol 2023. [PMID: 36976518 DOI: 10.1111/ene.15797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Stephanos Finitsis
- Department of Radiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anne Berberich
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen/Rhein, Germany
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen/Rhein, Germany
- Department of Neurology Heidelberg University Hospital, Heidelberg, Germany
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4
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Edwards C, Drumm B, Siegler JE, Schonewille WJ, Klein P, Huo X, Chen Y, Abdalkader M, Qureshi MM, Strbian D, Liu X, Hu W, Ji X, Li C, Fischer U, Nagel S, Puetz V, Michel P, Alemseged F, Sacco S, Yamagami H, Yaghi S, Strambo D, Kristoffersen ES, Sandset EC, Mikulik R, Tsivgoulis G, Masoud HE, de Sousa DA, Marto JP, Lobotesis K, Roi D, Berberich A, Demeestere J, Meinel TR, Rivera R, Poli S, Ton MD, Zhu Y, Li F, Sang H, Thomalla G, Parsons M, Campbell BCV, Zaidat OO, Chen HS, Field TS, Raymond J, Kaesmacher J, Nogueira RG, Jovin TG, Sun D, Liu R, Qureshi AI, Qiu Z, Miao Z, Banerjee S, Nguyen TN. Basilar artery occlusion management: Specialist perspectives from an international survey. J Neuroimaging 2023; 33:422-433. [PMID: 36781295 DOI: 10.1111/jon.13084] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Two early basilar artery occlusion (BAO) randomized controlled trials did not establish the superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to EVT versus medical management may differ between clinician specialties. METHODS We conducted an international survey (January 18, 2022 to March 31, 2022) regarding management strategies in acute BAO prior to the announcement of two trials indicating the superiority of EVT, and compared responses between interventionalists (INTs) and non-interventionalists (nINTs). Selection practices for routine EVT and perceptions of equipoise regarding randomizing to medical management based on neuroimaging and clinical features were compared between the two groups using descriptive statistics. RESULTS Among the 1245 respondents (nINTs = 702), INTs more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p < .01). A similar proportion of INTs and nINTs responded that they would not randomize a patient with BAO to EVT (29.4% vs. 26.7%), or that they would only under specific clinical circumstances (p = .45). Among respondents who would recommend EVT for BAO, there was no difference in the maximum prestroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p > .05), although nINTs more commonly preferred perfusion imaging (24.2% vs. 19.7%, p = .04). Among respondents who indicated they would randomize to medical management, INTs were more likely to randomize when the National Institutes of Health Stroke Scale was ≥10 (15.9% vs. 6.9%, p < .01). CONCLUSIONS Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a BAO patient to medical treatment. There were small differences in preference for advanced neuroimaging for patient selection, although these preferences were unsupported by clinical trial data at the time of the survey.
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Affiliation(s)
- Christopher Edwards
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Brian Drumm
- Department of Stroke Medicine, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | | | - Piers Klein
- Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Muhammad M Qureshi
- Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA.,Radiation Oncology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Xinfeng Liu
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Wei Hu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Urs Fischer
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Patrik Michel
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fana Alemseged
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Simona Sacco
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Davide Strambo
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Espen Saxhaug Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Department of General Practice, University of Oslo, Oslo, Norway
| | - Else C Sandset
- Department of Neurology, The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Robert Mikulik
- Department of Neurology, International Clinical Research Center, St Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Hesham E Masoud
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, New York, USA
| | - Diana Aguiar de Sousa
- Lisbon Central University Hospital and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Kyriakos Lobotesis
- Department of Radiology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Dylan Roi
- Department of Radiology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Anne Berberich
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Jelle Demeestere
- Neurology Department, Leuven University Hospital, Leuven, Belgium
| | - Thomas R Meinel
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rodrigo Rivera
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo, Santiago, Chile
| | - Sven Poli
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany.,Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
| | - Mai Duy Ton
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam.,Vietnam National University of Medicine and Pharmacy, Hanoi, Vietnam
| | - Yuyou Zhu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital of the Army Medical University, Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Mark Parsons
- Sydney Brain Center, University of New South Wales, Sydney, New South Wales, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Thalia S Field
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean Raymond
- Neuroradiologie Interventionelle, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Adnan I Qureshi
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Zhongming Qiu
- Hanoi Medical University, Hanoi, Vietnam.,Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Soma Banerjee
- Department of Stroke Medicine, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA.,Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
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5
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Edwards C, Drumm B, Siegler JE, Schonewille WJ, Klein P, Huo X, Chen Y, Strbian D, Liu X, Hu W, Ji X, Li C, Fischer U, Nagel S, Puetz V, Michel P, Alemseged F, Sacco S, Yamagami H, Abdalkader M, Yaghi S, Strambo D, Kristoffersen ES, Sandset EC, Mikulik R, Tsivgoulis G, Aguiar De Sousa D, Pedro Marto J, Lobotesis K, Roi D, Berberich A, Demeestere J, Meinel TR, Rivera R, Poli S, Duy Ton M, Zhu Y, Li F, Sang H, Thomalla G, Parsons M, Campbell BC, Chen HS, Raymond J, Nogueira RG, Jovin TG, Qiu Z, Miao Z, Banerjee S, Nguyen TN. Abstract TP153: Basilar Artery Occlusion Management: Specialist Perspectives From After The BEST Of BASICS Study. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Two early basilar artery occlusion (BAO) randomized controlled trials did not establish superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to medical management may differ between clinician specialties.
Methods:
We conducted an international survey (1/1/22-3/31/22) regarding management strategies in acute BAO prior to the announcement of 2 trials indicating superiority of EVT, and compared responses between interventionalists (INT) and non-interventionalists (nINT). Selection practices for routine EVT based on neuroimaging and clinical features were compared between the two groups using descriptive statistics.
Results:
Among the 1245 respondents (nINT=702), INT more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p<0.01). A similar proportion of INT and nINT responded that they would not randomize a patient with BAO to EVT (29.4% vs. 26.7%), or that they would only under specific circumstances (p=0.45). Among respondents who would recommend EVT, there was no difference in the maximum pre-stroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p>0.05), although nINT more commonly preferred perfusion imaging (24.2% vs. 19.7%, p=0.04). Among respondents who indicated they would randomize to medical management, INT were more likely to randomize when the NIHSS was ≥10 (15.9% vs. 6.9%, p<0.01).
Conclusions:
Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a patient to medical treatment. There were small differences in preference of advanced neuroimaging, although these preferences were unsupported by clinical trial data.
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Affiliation(s)
| | - Brian Drumm
- Imperial College London NHS Healthcare Trust, London, United Kingdom
| | | | | | | | | | - Yimin Chen
- Foshan Sanshui People’s Hosp, Foshan, China
| | | | - Xinfeng Liu
- Univ of Science and Technology of China, Heifei, China
| | - Wei Hu
- The First Affiliated Hosp of USTC, Hefei, China
| | | | | | | | | | | | - Patrik Michel
- Cntr? Hospier? Universitaire? Vaudois, Lausanne, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | - João Pedro Marto
- Dept of Clinical Neurosciences, Lausanne Univ Hosp, Lausanne, Switzerland
| | | | - Dylan Roi
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | | | | | - Sven Poli
- Dept of Neurology & Stroke, Hertie Institute for Clinical Brain Rsch, Germany
| | | | - Yuyou Zhu
- The First Affiliated Hosp of USTC, Hefei, China
| | - Fengli Li
- Xinqiao Hosp of the Army Med Univ, Chongqing, China
| | - Hongfei Sang
- Affiliated Hangzhou First People’s Hosp, Hangzhou, China
| | | | | | | | - Hui-Sheng Chen
- General Hosp of Shenyang Military Region, Shenyang, China
| | - Jean Raymond
- Cntr Hospier de l’Universite de Montreal, Montreal, Canada
| | | | | | - Zhongming Qiu
- The 903rd Hosp of The Chinese People's Liberation Army, Chongqing, China
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6
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Kebir S, Lazaridis L, Wick W, Platten M, Tabatabai G, Combs S, Schmidt T, Agkatsev S, Blau T, Mäurer I, Kahlert U, Sagerer A, Berberich A, Heider S, Müther M, Bodensohn R, Behling F. DISP-11. GENDER DISPARITY REGARDING WORK-LIFE BALANCE SATISFACTION AMONG GERMAN NEURO-ONCOLOGISTS: A YOUNGNOA SURVEY. Neuro Oncol 2022. [PMCID: PMC9660391 DOI: 10.1093/neuonc/noac209.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
PURPOSE
Satisfaction with work-life balance (WLB) is an essential factor for persistent motivation of early career researchers. However, WLB satisfaction in the neuro-oncological landscape is not well characterized. We present the results of an interdisciplinary survey focusing on WLB satisfaction among neuro-oncologists in Germany.
METHODS
The questionnaire was sent to 351 physicians, all of whom were members of the Neuro-oncology Working Group “Neuroonkologische Arbeitsgemeinschaft” (NOA) of the German Cancer Society (Deutsche Krebsgesellschaft, DKG). The participants were asked for personal information, individual motivations, scientific interests, activities, individual workload, and job satisfaction. The questionnaire was accessible from 18 March 2021 to 1 April 2021.
RESULTS
Ninety-six physicians (36 female, 60 male) participated in this survey. Age, gender and relationship status were significantly different between participants who were satisfied and those not satisfied with their WLB. Female participants were less likely to be satisfied with their WLB than male participants (25% vs 75%, p = 0.005). In a logistic regression model, the finding that female participants were less likely to be satisfied with their WLB than male participants remained statistically significant (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.21–0.84, p = 0.023) after accounting for possible confounding variables such as age (OR 1.06; 95% CI 1.01–1.11, p = 0.025), childlessness (children available vs not available, OR 0.40; 95% CI 0.10–1.35, p = 0.156), and relationship status (unmarried vs single, OR 2.49; 95% CI 0.50–13.98, p = 0.275; married vs single, OR 6.18; 95% CI 1.29–35.46, p = 0.029).
CONCLUSIONS
This survey demonstrates that WLB satisfaction is significantly decreased among female neuro-oncologists in Germany. It highlights the importance of programs such as “Diversity in Neurooncology” (DivINe), founded by the NOA and aiming to address gender disparities.
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Affiliation(s)
- Sied Kebir
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany , Essen , Germany
| | - Lazaros Lazaridis
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany , Essen , Germany
| | - Wolfgang Wick
- Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg , Baden-Wurttemberg , Germany
| | | | - Ghazaleh Tabatabai
- Department of Neurology & Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Hertie Institute for Clincial Brain Research , Tübingen , Germany
| | - Stephanie Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
| | - Teresa Schmidt
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany , Essen , Germany
| | - Sarina Agkatsev
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany , Essen , Germany
| | - Tobias Blau
- Institute of Neuropathology, University Medicine Essen, University Duisburg-Essen, Essen, Germany , Essen , USA
| | - Irina Mäurer
- Hans Berger Department of Neurology, Jena University Hospital , Jena , Germany
| | - Ulf Kahlert
- Molecular and Experimental Surgery, University Clinic for General-, Visceral-, Vascular- and Transplantation Surgery, Faculty of Medicine, Otto-von-Guericke-University , Magdeburg , Germany
| | - Andre Sagerer
- Department of Neurosurgery, Universität Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, University of Heidelberg , Heidelberg , Germany
| | - Sina Heider
- Department of Radiotherapy and Radiation Oncology, University Hospital Leipzig, Leipzig, Germany , Leipzig , Germany
| | - Michael Müther
- Department of Neurosurgery, Münster University Hospital , Münster , Germany
| | - Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich , Munich , Germany
| | - Felix Behling
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen , Tübingen , Germany
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7
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Kebir S, Lazaridis L, Wick W, Platten M, Tabatabai G, Combs SE, Schmidt T, Agkatsev S, Blau T, Mäurer I, Kahlert U, Sagerer A, Berberich A, Heider S, Müther M, Bodensohn R, Behling F. Gender disparity regarding work-life balance satisfaction among German neuro-oncologists: a YoungNOA survey. Neuro Oncol 2022; 24:1609-1611. [PMID: 35639965 PMCID: PMC9435481 DOI: 10.1093/neuonc/noac114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Affiliation(s)
- Sied Kebir
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Lazaros Lazaridis
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), University of Heidelberg, Mannheim, Germany
| | - Ghazaleh Tabatabai
- Department of Neurology & Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Hertie Institute for Clinical Brain Research, Center for Neuro-Oncology, Comprehensive Cancer Center, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Helmholtz Zentrum München (HMGU), Oberschleißheim, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
| | - Teresa Schmidt
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Sarina Agkatsev
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Tobias Blau
- Institute of Neuropathology, University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Irina Mäurer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Ulf Kahlert
- Molecular and Experimental Surgery, Department of General, Visceral, Vascular, and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Andre Sagerer
- Department of Neurosurgery, Universität Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Sina Heider
- Department of Radiation Oncology, University of Leipzig, Leipzig, Germany
| | - Michael Müther
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Felix Behling
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany (F.B.)
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8
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Purrucker JC, Ringleb PA, Seker F, Potreck A, Nagel S, Schönenberger S, Berberich A, Neuberger U, Möhlenbruch M, Weyland C. Leaving the day behind: endovascular therapy beyond 24 h in acute stroke of the anterior and posterior circulation. Ther Adv Neurol Disord 2022; 15:17562864221101083. [PMID: 35646160 PMCID: PMC9136439 DOI: 10.1177/17562864221101083] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/28/2022] [Indexed: 11/15/2022] Open
Abstract
Background: There is little evidence of endovascular therapy (EVT) being performed in acute ischemic stroke beyond 24 h, and that evidence is limited to anterior circulation stroke. Objective: To extend evidence of efficacy and safety of EVT after more than 24 h in both anterior and posterior circulation stroke. Methods: Local, prospectively collected registries were screened for patients with acute ischemic stroke and large-vessel occlusion who had received either EVT > 24 h after last-seen-well but <24 h after symptom recognition (EVT>24LSW) or EVT > 24 h since first (definitive) symptom recognition (EVT>24DEF). Patients treated <24 h served as a group for comparison. Favorable outcome was defined as modified Rankin scale (mRS) 0–2 or return to prestroke mRS at 3 months. Results: Between January 2014 and August 2021, N = 2347 were treated with EVT at our comprehensive stroke center, of whom n = 43 met the inclusion criteria (EVT>24LSW, n = 16, EVT>24DEF, n = 27). EVT>24LSW patients were treated at a median of 28.7 h [interquartile range (IQR) = 27.3–32.8] after last-seen-well and 7.3 h (IQR = 2.8–14.3) after symptom recognition; EVT>24DEF patients were treated 52.5 h (IQR = 26.5–94.2) after first symptoms. Favorable outcome was achieved by 23.3% (10/43) in the EVT > 24 compared with 39.4% (886/2250) in the EVT < 24 group (p = 0.04). Bleeding rates were similar across groups. Mortality was also similar [EVT > 24, 27.9% (12/43) versus EVT < 24, 25.7% (584/2264), p = 0.727; posterior circulation, EVT > 24, 41.7% (5/12) versus EVT < 24, 36.5% (92/252) p = 0.764]. Conclusion: In selected patients, EVT seems effective and safe beyond 24 h for both anterior and posterior circulation stroke.
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Affiliation(s)
- Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arne Potreck
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Charlotte Weyland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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9
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Berberich A, Finitsis S, Strambo D, Michel P, Herweh C, Meyer L, Hanning U, Strbian D, Abdalkader M, Nogueira RG, Puetz V, Kaiser DPO, Olive-Gadea M, Ribo M, Fragata I, Marto JP, Romoli M, Ringleb PA, Nguyen TN, Nagel S. Endovascular Therapy versus No Endovascular Therapy in Patients receiving Best Medical Management for Acute Isolated Occlusion of the Posterior Cerebral Artery: Systematic Review and Meta-Analysis. Eur J Neurol 2022; 29:2664-2673. [PMID: 35587104 DOI: 10.1111/ene.15410] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy (EVT) is increasingly reported for treatment of isolated posterior cerebral artery (PCA) occlusions although its clinical benefit remains uncertain. This study-level meta-analysis investigated functional outcome and safety of EVT and best medical management (BMM) compared to BMM for treatment of PCA occlusion stroke. METHODS We conducted a literature search in PubMed, Web of Science and Embase for articles reporting patients with isolated PCA occlusion stroke treated with EVT+BMM or BMM including intravenous thrombolysis. There were no randomized trials and all studies were retrospective. Primary outcome was a modified Rankin Scale score of 0-2 at 3 months; safety outcomes included mortality rate and incidence of symptomatic intracranial hemorrhage. RESULTS Twelve articles with a total of 679 patients were included in the meta-analysis consisting of 338 patients with EVT+BMM and 341 patients receiving BMM alone. Good functional outcome at 3 months was achieved in 58.0% [95% confidence interval (CI) 43.83-70.95] of patients with EVT+BMM and 48.1% [95% CI 40.35-55.92] of patients with BMM with respective mortality rates of 12.6% [7.30-20.93] and 12.3% [8.64-17.33]. Symptomatic intracranial hemorrhage occurred in 4.2% [95% CI 2.47-7.03] of patients with EVT+BMM and 3.2% [95% CI 1.75-5.92] of patients with BMM. Comparative analyses were performed of publications reporting both treatments and demonstrated no significant differences. CONCLUSIONS The results demonstrate that EVT represents a safe treatment for patients with isolated PCA occlusion stroke. There were no differences in clinical or safety outcomes between treatments, supporting randomization of future patients into distal vessel occlusion trials.
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Affiliation(s)
- Anne Berberich
- Department of Neurology Heidelberg University Hospital, Heidelberg, Germany
| | | | - Davide Strambo
- Department of Neurology, Lausanne University Hospital and University of Lasaunne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital and University of Lasaunne, Lausanne, Switzerland
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Lukas Meyer
- Department of Radiology, Hamburg University Hospital, Hamburg, Germany
| | - Uta Hanning
- Department of Radiology, Hamburg University Hospital, Hamburg, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | | | - Raul G Nogueira
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Volker Puetz
- Department of Neurology, Dresden University Hospital, Dresden, Germany.,Dresden Neurovascular Center, Dresden University Hospital, Dresden, Germany
| | - Daniel P O Kaiser
- Dresden Neurovascular Center, Dresden University Hospital, Dresden, Germany.,Institute of Neuroradiology, Dresden University Hospital, Dresden, Germany
| | - Marta Olive-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Peter A Ringleb
- Department of Neurology Heidelberg University Hospital, Heidelberg, Germany
| | - Thanh N Nguyen
- Department of Neurology, Radiology Boston Medical Center, Boston, USA
| | - Simon Nagel
- Department of Neurology Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen/Rhein, Germany
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10
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Ciprut S, Berberich A, Knoll M, Pusch S, Hoffmann D, Furkel J, Ward Gahlawat A, Kahlert-Konzelamnn L, Sahm F, Warnken U, Winter M, Schnölzer M, Pusch S, von Deimling A, Abdollahi A, Wick W, Lemke D. AAMP is a binding partner of costimulatory human B7-H3. Neurooncol Adv 2022; 4:vdac098. [PMID: 35919070 PMCID: PMC9341442 DOI: 10.1093/noajnl/vdac098] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Targeted immunotherapies are of growing interest in the treatment of various cancers. B7 homolog 3 protein (B7-H3), a member of the co-stimulatory/-inhibitory B7-family, exerts immunosuppressive and pro-tumorigenic functions in various cancer types and is under evaluation in ongoing clinical trials. Unfortunately, interaction partner(s) remain unknown which restricts the druggability. Methods Aiming to identify potential binding partner(s) of B7-H3, a yeast two-hybrid and a mass spectrometry screen were performed. Potential candidates were evaluated by bimolecular fluorescence complementation (BiFC) assay, co-immunoprecipitation (co-IP), and functionally in a 3H-thymidine proliferation assay of Jurkat cells, a T-cell lineage cell line. Prognostic value of angio-associated migratory cell protein (AAMP) and B7-H3 expression was evaluated in isocitrate dehydrogenase 1 wildtype (IDH1wt) glioblastoma (GBM) patients from The Cancer Genome Atlas (TCGA)-GBM cohort. Results Of the screening candidates, CD164, AAMP, PTPRA, and SLAMF7 could be substantiated via BiFC. AAMP binding could be further confirmed via co-IP and on a functional level. AAMP was ubiquitously expressed in glioma cells, immune cells, and glioma tissue, but did not correlate with glioma grade. Finally, an interaction between AAMP and B7-H3 could be observed on expression level, hinting toward a combined synergistic effect. Conclusions AAMP was identified as a novel interaction partner of B7-H3, opening new possibilities to create a targeted therapy against the pro-tumorigenic costimulatory protein B7-H3.
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Affiliation(s)
- Sara Ciprut
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Anne Berberich
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Maximilian Knoll
- Clinical Cooperation Unit Translational Radiation Oncology, German Cancer Consortium (DKTK) Core Center Heidelberg, German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Stefan Pusch
- German Consortium of Translational Cancer Research (DKTK), Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neuropathology, Institute of Pathology, Ruprecht-Karls-University Heidelberg , Heidelberg , Germany
| | - Dirk Hoffmann
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT) , Heidelberg , Germany
- Faculty of Biosciences, Heidelberg University , Heidelberg , Germany
| | - Jennifer Furkel
- Clinical Cooperation Unit Translational Radiation Oncology, German Cancer Consortium (DKTK) Core Center Heidelberg, German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Aoife Ward Gahlawat
- Clinical Cooperation Unit Translational Radiation Oncology, German Cancer Consortium (DKTK) Core Center Heidelberg, German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Lena Kahlert-Konzelamnn
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Felix Sahm
- German Consortium of Translational Cancer Research (DKTK), Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neuropathology, Institute of Pathology, Ruprecht-Karls-University Heidelberg , Heidelberg , Germany
| | - Uwe Warnken
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Martin Winter
- Department of Functional Proteome Analysis, German Cancer Research Center (DKFZ) , Heidelberg , Germany
| | - Martina Schnölzer
- Department of Functional Proteome Analysis, German Cancer Research Center (DKFZ) , Heidelberg , Germany
| | - Sonja Pusch
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Andreas von Deimling
- German Consortium of Translational Cancer Research (DKTK), Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neuropathology, Institute of Pathology, Ruprecht-Karls-University Heidelberg , Heidelberg , Germany
| | - Amir Abdollahi
- Clinical Cooperation Unit Translational Radiation Oncology, German Cancer Consortium (DKTK) Core Center Heidelberg, German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Dieter Lemke
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) , Heidelberg , Germany
- Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT) , Heidelberg , Germany
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11
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Kaiser DPO, Abdalkader M, Berberich A, Sporns PB, Nguyen TN. Acute shortage of iodinated contrast media: implications and guidance for neurovascular imaging and intervention. Neuroradiology 2022; 64:1715-1718. [PMID: 35716206 PMCID: PMC9206091 DOI: 10.1007/s00234-022-02999-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/10/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel P. O. Kaiser
- grid.4488.00000 0001 2111 7257Else Kröner Fresenius Center for Digital Health, TU Dresden, Dresden, Germany ,grid.4488.00000 0001 2111 7257Institut Und Poliklinik Für Diagnostische Und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Mohamad Abdalkader
- grid.239424.a0000 0001 2183 6745Department of Radiology, Boston Medical Center, Boston, MA USA
| | - Anne Berberich
- grid.5253.10000 0001 0328 4908Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter B. Sporns
- grid.410567.1Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland ,grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thanh N. Nguyen
- grid.239424.a0000 0001 2183 6745Department of Neurology, Radiology Boston Medical Center, Boston, MA USA
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12
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Heyse M, Schneider C, Monostori P, Schwarz KV, Hauke J, Drüschler K, Berberich A, Zorn M, Ringleb PA, Okun JG, Mundiyanapurath S. Trimethylamine-N-Oxide Levels Are Similar in Asymptomatic vs. Symptomatic Cerebrovascular Atherosclerosis. Front Neurol 2021; 12:617944. [PMID: 33815248 PMCID: PMC8017230 DOI: 10.3389/fneur.2021.617944] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/22/2021] [Indexed: 01/02/2023] Open
Abstract
Introduction: Trimethylamine-N-oxide (TMAO) is correlated with atherosclerosis and vascular diseases such as coronary heart disease and ischemic stroke. The aim of the study was to investigate whether TMAO levels are different in symptomatic vs. asymptomatic cerebrovascular atherosclerosis. Methods: This was a prospective, case-control study, conducted at a tertiary care university hospital. Patients were included if they had large-artery atherosclerosis (TOAST criteria). Symptomatic patients with ischemic stroke were compared with asymptomatic patients. As primary endpoint, TMAO levels on admission were compared between symptomatic and asymptomatic patients. Univariable analysis was performed using Mann-Whitney U test and multivariable analysis using binary logistic regression. TMAO values were adjusted for glomerular filtration rate (GFR), age, and smoking. Results: Between 2018 and 2020, 82 symptomatic and asymptomatic patients were recruited. Median age was 70 years; 65% were male. Comparing symptomatic (n = 42) and asymptomatic (n = 40) patients, no significant differences were found in univariable analysis in TMAO [3.96 (IQR 2.30-6.73) vs. 5.36 (3.59-8.68) μmol/L; p = 0.055], GFR [87 (72-97) vs. 82 (71-90) ml/min*1.73 m2; p = 0.189] and age [71 (60-79) vs. 69 (67-75) years; p = 0.756]. In multivariable analysis, TMAO was not a predictor of symptomatic cerebrovascular disease after adjusting for age and GFR [OR 1.003 (95% CI: 0.941-1.070); p = 0.920]. In a sensitivity analysis, we only analyzed patients with symptomatic stenosis and excluded patients with occlusion of brain-supplying arteries. Again, TMAO was not a significant predictor of symptomatic stenosis [OR 1.039 (0.965-1.120), p = 0.311]. Conclusion: TMAO levels could not be used to differentiate between symptomatic and asymptomatic cerebrovascular disease in our study.
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Affiliation(s)
- Miriam Heyse
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christine Schneider
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Monostori
- Metabolic and Newborn Screening Laboratory, Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Kathrin V Schwarz
- Division of Child Neurology and Metabolic Medicine, Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jana Hauke
- Division of Child Neurology and Metabolic Medicine, Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Drüschler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Zorn
- Central Laboratory, Department of Internal Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen G Okun
- Division of Child Neurology and Metabolic Medicine, Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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13
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Burth S, Ohmann M, Kronsteiner D, Kieser M, Löw S, Riedemann L, Laible M, Berberich A, Drüschler K, Rizos T, Wick A, Winkler F, Wick W, Nagel S. Prophylactic anticoagulation in patients with glioblastoma or brain metastases and atrial fibrillation: an increased risk for intracranial hemorrhage? J Neurooncol 2021; 152:483-490. [PMID: 33674992 PMCID: PMC8084835 DOI: 10.1007/s11060-021-03716-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/12/2021] [Indexed: 11/27/2022]
Abstract
Purpose Patients with glioblastoma (GBM) or brain metastases (MET) and atrial fibrillation (AF) might be at an increased risk of intracranial hemorrhage (ICH) due to anticoagulation (AC). Our aim was to assess this risk. Methods Our institution’s database (from 2005 to 2017) was screened for patients with GBM or MET and AF with an indication for AC according to their CHA2DS2VASc stroke risk score (≥ 2). Required follow-up was at least 3 months. AC was either performed with heparins, phenprocoumon or non-Vitamin K antagonist oral anticoagulants. Applying the propensity score approach, patient cohorts (matched according to primary tumor, age, sex) were generated (GBM [or MET] with AF ± AC, GBM [or MET] without AF/AC, no GBM [or MET] but AF on AC). ICH was defined as clinical deterioration caused by new blood on imaging. A log rank test was performed to compare the risk for ICH between the three groups. Results In total, 104 patients were identified of which 49 with GBM (37% on AC) and 37 with MET (46% on AC) were successfully matched. Median follow up was 8.6 and 7.2 months, respectively. ICH occurred in 10.2% of GBM + AF and 12.2% GBM-AF, whereas 8% of patients with AF on AC suffered ICH (p = 0.076). 13.5% of patients with MET + AF had ICHs, in the controls it was 16% for MET-AF and 8% for AF on AC (p = 0.11). Conclusion AC did not seem to influence the incidence of ICH in patients with glioblastoma or brain metastases within follow up of just under 9 months. Supplementary Information The online version contains supplementary material available at 10.1007/s11060-021-03716-8.
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Affiliation(s)
- Sina Burth
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Mona Ohmann
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Sarah Löw
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Lars Riedemann
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Mona Laible
- Department of Neurology, Ulm University Hospital, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Katharina Drüschler
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Antje Wick
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Frank Winkler
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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14
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Seker F, Pfaff JAR, Mokli Y, Berberich A, Namias R, Gerry S, Nagel S, Bendszus M, Herweh C. Diagnostic accuracy of automated occlusion detection in CT angiography using e-CTA. Int J Stroke 2021; 17:77-82. [PMID: 33527886 PMCID: PMC8739618 DOI: 10.1177/1747493021992592] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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] [Indexed: 12/25/2022]
Abstract
Background and aim The aim of this study was to assess the diagnostic accuracy of e-CTA (product name) (Brainomix) in the automatic detection of large vessel occlusions in anterior circulation stroke. Methods Of 487 CT angiographies from patients with large vessel occlusions stroke, 327 were used to train the algorithm while the remaining cases together with 140 negative CT angiographies were used to validate its performance against ground truth. Of these 301 cases, 144 were randomly selected and used for an additional comparative analysis against 4 raters. Sensitivity, specificity, positive and negative predictive value (PPV and NPV), accuracy and level of agreement with ground truth (Cohen’s Kappa) were determined and compared to the performance of a neuroradiologist, a radiology resident, and two neurology residents. Results e-CTA had a sensitivity and specificity of 0.84 (0.77–0.89) and 0.96 (0.91–0.98) respectively for the detection of any large vessel occlusions on the correct side in the whole validation cohort. This performance was identical in the comparative analysis subgroup and was within the range of physicians at different levels of expertise: 0.86–0.97 and 0.91–1.00, respectively. For the detection of proximal occlusions, it was 0.92 (0.84–0.96) and 0.98 (0.94–1.00) for the whole cohort and 0.93 (0.80–0.98) and 1.00 (0.95–1.00) for the comparative analysis, respectively for e-CTA. The range was 0.8–0.97 for sensitivity and 0.97–1.00 for specificity for the four physicians. Conclusions The performance of e-CTA in detecting any large vessel occlusions is comparable to less experienced physicians but is similar to experienced physicians for detecting proximal large vessel occlusions.
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Affiliation(s)
- Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Yahia Mokli
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Steven Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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15
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Kessler T, Berberich A, Sadik A, Sahm F, Gorlia T, Meisner C, Hoffmann DC, Wick A, Kickingereder P, Rübmann P, Bendszus M, Opitz C, Weller M, van den Bent M, Stupp R, Winkler F, Brandes A, von Deimling A, Platten M, Wick W. Methylome analyses of three glioblastoma cohorts reveal chemotherapy sensitivity markers within DDR genes. Cancer Med 2020; 9:8373-8385. [PMID: 32991787 PMCID: PMC7666733 DOI: 10.1002/cam4.3447] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/30/2020] [Accepted: 08/14/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Gliomas evade current therapies through primary and acquired resistance and the effect of temozolomide is mainly restricted to methylguanin-O6-methyltransferase promoter (MGMT) promoter hypermethylated tumors. Further resistance markers are largely unknown and would help for better stratification. METHODS Clinical data and methylation profiles from the NOA-08 (104, elderly glioblastoma) and the EORTC 26101 (297, glioblastoma) studies and 398 patients with glioblastoma from the Heidelberg Neuro-Oncology center have been analyzed focused on the predictive effect of DNA damage response (DDR) gene methylation. Candidate genes were validated in vitro. RESULTS Twenty-eight glioblastoma 5'-cytosine-phosphat-guanine-3' (CpGs) from 17 DDR genes negatively correlated with expression and were used together with telomerase reverse transcriptase (TERT) promoter mutations in further analysis. CpG methylation of DDR genes shows highest association with the mesenchymal (MES) and receptor tyrosine kinase (RTK) II glioblastoma subgroup. MES tumors have lower tumor purity compared to RTK I and II subgroup tumors. CpG hypomethylation of DDR genes TP73 and PRPF19 correlated with worse patient survival in particular in MGMT promoter unmethylated tumors. TERT promoter mutation is most frequent in RTK I and II subtypes and associated with worse survival. Primary glioma cells show methylation patterns that resemble RTK I and II glioblastoma and long term established glioma cell lines do not match with glioblastoma subtypes. Silencing of selected resistance genes PRPF19 and TERT increase sensitivity to temozolomide in vitro. CONCLUSION Hypomethylation of DDR genes and TERT promoter mutations is associated with worse tumor prognosis, dependent on the methylation cluster and MGMT promoter methylation status in IDH wild-type glioblastoma.
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Affiliation(s)
- Tobias Kessler
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neurooncology Program of the National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Anne Berberich
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neurooncology Program of the National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Ahmed Sadik
- Brain Tumor Metabolism, DKTK, DKFZ, Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, DKTK, DKFZ, Heidelberg, Germany
| | - Thierry Gorlia
- European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | | | - Dirk C Hoffmann
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neurooncology Program of the National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany.,Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Antje Wick
- Department of Neurology and Neurooncology Program of the National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Petra Rübmann
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Martin van den Bent
- The Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Roger Stupp
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Frank Winkler
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neurooncology Program of the National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Alba Brandes
- Department of Medical Oncology, Azienda USL-IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Andreas von Deimling
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, DKTK, DKFZ, Heidelberg, Germany
| | - Michael Platten
- Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, DKTK, DKFZ, Heidelberg, Germany.,Department of Neurology, Medical Faculty Mannheim, MCTN, Heidelberg University, Mannheim, Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neurooncology Program of the National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
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16
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Altersberger VL, Sturzenegger R, Räty S, Hametner C, Scheitz JF, Moulin S, Berg SA, Zini A, Nannoni S, Heldner MR, Jovanovic DR, Martinez‐Majander N, Tiainen M, Valkonen K, Berberich A, Erdur H, Cordonnier C, Peters N, Gopisingh KM, Bigliardi G, Strambo D, De Marchis GM, Ntaios G, Cereda CW, Wegener S, Kägi G, Pezzini A, Padjen V, Arnold M, Michel P, Vandelli L, Nederkoorn PJ, Leys D, Nolte CH, Ringleb PA, Curtze S, Engelter ST, Gensicke H. Prior Dual Antiplatelet Therapy and Thrombolysis in Acute Stroke. Ann Neurol 2020; 88:857-859. [DOI: 10.1002/ana.25850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Valerian L. Altersberger
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
| | | | - Silja Räty
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Christian Hametner
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Jan F. Scheitz
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | - Solène Moulin
- Department of Neurology Centre Hospitalier Universitaire de Reims Reims France
| | - Sophie A. Berg
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | - Andrea Zini
- Department of Neurology and Stroke Center IRCCS Istituto di Scienze Neurologiche di Bologna, Maggiore Hospital Bologna Italy
| | - Stefania Nannoni
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital Bern University Hospital and University of Bern Bern Switzerland
| | - Dejana R. Jovanovic
- Neurology Clinic, Clinical Centre of Serbia Belgrade Serbia
- Medical Faculty University of Belgrade Belgrade Serbia
| | | | - Marjaana Tiainen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Kati Valkonen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Anne Berberich
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Hebun Erdur
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | | | - Nils Peters
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
| | - Kiran M. Gopisingh
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | - Guido Bigliardi
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile “S. Agostino‐Estense,” Modena University Hospital Modena Italy
| | - Davide Strambo
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Gian M. De Marchis
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine School of Health Sciences, University of Thessaly Larissa Greece
| | - Carlo W. Cereda
- Stroke Center and Department of Neurology Neurocenter of Southern Switzerland Lugano Switzerland
| | - Susanne Wegener
- Department of Neurology University Hospital Zurich and University of Zurich Zurich Switzerland
| | - Georg Kägi
- Department of Neurology Kantonsspital St. Gallen St. Gallen Switzerland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences Neurology Clinic, University of Brescia Brescia Italy
| | - Visnja Padjen
- Neurology Clinic, Clinical Centre of Serbia Belgrade Serbia
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern University Hospital and University of Bern Bern Switzerland
| | - Patrik Michel
- Department of Neurology Centre Hospitalier Universitaire Vaudois and University of Lausanne Lausanne Switzerland
| | - Laura Vandelli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile “S. Agostino‐Estense,” Modena University Hospital Modena Italy
| | - Paul J. Nederkoorn
- Department of Neurology Amsterdam University Medical Center, University of Amsterdam Amsterdam The Netherlands
| | | | - Christian H. Nolte
- Department of Neurology and Center for Stroke Research Berlin Charité, Berlin Germany
| | - Peter A. Ringleb
- Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Sami Curtze
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Stefan T. Engelter
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
| | - Henrik Gensicke
- Stroke Center and Department of Neurology University Hospital Basel and University of Basel Basel Switzerland
- Neurorehabilitation, University of Basel and University Department of Geriatric Medicine FELIX PLATTER University of Basel Basel Switzerland
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17
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Ungerer M, Begli NH, Heyse M, Purrucker J, Regula J, Berberich A, Ciolli L, Nagel S, Ringleb P, Gumbinger C. Patient profiles contribute to differences in quality metrics of stroke centers. NSJ 2020; 25:292-300. [PMID: 33130810 PMCID: PMC8015612 DOI: 10.17712/nsj.2020.4.20190100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives: To examine this association by comparing patient profiles in 2 closely affiliated hospitals and by examining their association with quality metrics. Methods: We performed a retrospective cohort study comparing a university level comprehensive stroke centers (CSC) with its teaching hospital and local stroke unit (LSU) using routinely collected quality assurance data over a 2 year period. Both hospitals were closely affiliated, shared important resources and medical staff rotated amongst both hospitals. We compared patient profiles as well as internationally recognized quality metrics and examined the association of profiles with quality metrics. Results: A total of 2,462 patients were treated in the CSC and 726 in the LSU. The LSU had a longer door-to-image and door-to-needle times. Rate of systemic thrombolysis was lower in the LSU. Patient profiles differed significantly and were associated with door-to-image and door-to-needle times as well as intravenous thrombolysis rates, even when adjusted for stroke service level. The diagnostic procedures for stroke work-up were similar. Discharge management differed strongly. Conclusion: Although LSUs and CSCs are the primary care providers in their respective regions, differences in patient profiles may contribute to differences in performance parameters. Adjusting for patient profiles may improve the comparability of the quality of stroke care provided by hospitals belonging to different stroke service levels.
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Affiliation(s)
- Matthias Ungerer
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Nima Haji Begli
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Miriam Heyse
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Jan Purrucker
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Jens Regula
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Anne Berberich
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Ludovico Ciolli
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Simon Nagel
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Peter Ringleb
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Christoph Gumbinger
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
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Berberich A, Bartels F, Tang Z, Knoll M, Pusch S, Hucke N, Kessler T, Dong Z, Wiestler B, Winkler F, Platten M, Wick W, Abdollahi A, Lemke D. LAPTM5-CD40 Crosstalk in Glioblastoma Invasion and Temozolomide Resistance. Front Oncol 2020; 10:747. [PMID: 32582531 PMCID: PMC7289993 DOI: 10.3389/fonc.2020.00747] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 01/09/2020] [Accepted: 04/20/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Glioma therapy is challenged by the diffuse and invasive growth of glioma. Lysosomal protein transmembrane 5 (LAPTM5) was identified as an invasion inhibitor by an in vivo screen for invasion-associated genes. The aim of this study was to decipher the function of LAPTM5 in glioblastoma and its interaction with the CD40 receptor which is intensively evaluated as a target in the therapy of diverse cancers including glioma. Methods: Knockdown of LAPTM5 was performed in different glioma cell lines to analyze the impact on clonogenicity, invasiveness, sensitivity to temozolomide chemotherapy, and tumorigenicity in vitro and in vivo. An expression array was used to elucidate the underlying pathways. CD40 knockdown and overexpression were induced to investigate a potential crosstalk of LAPTM5 and CD40. LAPTM5 and CD40 were correlated with the clinical outcome of glioma patients. Results: Knockdown of LAPTM5 unleashed CD40-mediated NFκB activation, resulting in enhanced invasiveness, clonogenicity, and temozolomide resistance that was overcome by NFκB inhibition. LAPTM5 expression correlated with better overall survival in glioblastoma patients depending on CD40 expression status. Conclusion: We conclude that LAPTM5 conveyed tumor suppression and temozolomide sensitation in CD40-positive glioblastoma through the inhibition of CD40-mediated NFκB activation. Hence, LAPTM5 may provide a potential biomarker for sensitivity to temozolomide in CD40-positive glioblastoma.
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Affiliation(s)
- Anne Berberich
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Frederik Bartels
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Zili Tang
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, Heidelberg Ion Therapy Center (HIT), German Cancer Research Center (DKFZ), Heidelberg Institute of Radiation Oncology (HIRO), University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Maximilian Knoll
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, Heidelberg Ion Therapy Center (HIT), German Cancer Research Center (DKFZ), Heidelberg Institute of Radiation Oncology (HIRO), University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Sonja Pusch
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Nanina Hucke
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Tobias Kessler
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Zhen Dong
- Department of Neurosurgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universität, Munich, Germany
| | - Frank Winkler
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany.,DKTK Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Wick
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Amir Abdollahi
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, Heidelberg Ion Therapy Center (HIT), German Cancer Research Center (DKFZ), Heidelberg Institute of Radiation Oncology (HIRO), University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Dieter Lemke
- German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Neurology, University of Heidelberg Medical School and National Center for Tumor Diseases (NCT), Heidelberg, Germany
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19
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Wick W, Dettmer S, Berberich A, Kessler T, Karapanagiotou-Schenkel I, Wick A, Winkler F, Pfaff E, Brors B, Debus J, Unterberg A, Bendszus M, Herold-Mende C, Eisenmenger A, von Deimling A, Jones DTW, Pfister SM, Sahm F, Platten M. N2M2 (NOA-20) phase I/II trial of molecularly matched targeted therapies plus radiotherapy in patients with newly diagnosed non-MGMT hypermethylated glioblastoma. Neuro Oncol 2020; 21:95-105. [PMID: 30277538 DOI: 10.1093/neuonc/noy161] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Patients with glioblastoma without O6-methylguanine-DNA methyltransferase (MGMT) promoter hypermethylation are unlikely to benefit from alkylating chemotherapy with temozolomide (TMZ). Trials aiming at replacing TMZ with targeted agents in unselected patient populations have failed to demonstrate any improvement of survival. Advances in molecular understanding and diagnostic precision enable identification of key genetic alterations in a timely manner and in principle allow treatments with targeted compounds based on molecular markers. Methods The NCT Neuro Master Match (N2M2) trial is an open-label, multicenter, phase I/IIa umbrella trial for patients with newly diagnosed isocitrate dehydrogenase (IDH) wildtype glioblastoma without MGMT promoter hypermethylation to show safety, feasibility, and preliminary efficacy of treatment with targeted compounds in addition to standard radiotherapy based on molecular characterization. N2M2 is formally divided into a Discovery and a Treatment part. Discovery includes broad molecular neuropathological diagnostics to detect predefined biomarkers for targeted treatments. Molecular diagnostics and bioinformatic evaluation are performed within 4 weeks, allowing a timely initiation of postoperative treatment. Stratification for Treatment takes place in 5 subtrials, including alectinib, idasanutlin, palbociclib, vismodegib, and temsirolimus as targeted therapies, according to the best matching molecular alteration. Patients without matching alterations are randomized between subtrials without strong biomarkers using atezolizumab and asinercept (APG101) and the standard of care, TMZ. For the phase I parts, a Bayesian criterion is used for continuous monitoring of toxicity. In the phase II trials, progression-free survival at 6 months is used as endpoint for efficacy. Results Molecular diagnostics and bioinformatic evaluation are performed within 4 weeks, allowing a timely initiation of postoperative treatment. Stratification for Treatment takes place in 5 subtrials, including alectinib, idasanutlin, palbociclib, vismodegib, and temsirolimus as targeted therapies, according to the best matching molecular alteration. Patients without matching alterations are randomized between subtrials without strong biomarkers using atezolizumab and asinercept (APG101) and the standard of care, TMZ. For the phase I parts, a Bayesian criterion is used for continuous monitoring of toxicity. In the phase II trials, progression-free survival at 6 months is used as endpoint for efficacy. Discussion Molecularly informed trials may provide the basis for the development of predictive biomarkers and help to understand and select patient subgroups who will benefit.
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Affiliation(s)
- Wolfgang Wick
- Clinical Cooperation Unit Neuro-oncology, German Cancer Consortium (DKTK), German Cancer Research Center(DKFZ), Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Susan Dettmer
- NCT Trial Center, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anne Berberich
- Clinical Cooperation Unit Neuro-oncology, German Cancer Consortium (DKTK), German Cancer Research Center(DKFZ), Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Kessler
- Clinical Cooperation Unit Neuro-oncology, German Cancer Consortium (DKTK), German Cancer Research Center(DKFZ), Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Irini Karapanagiotou-Schenkel
- NCT Trial Center, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Antje Wick
- Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Frank Winkler
- Clinical Cooperation Unit Neuro-oncology, German Cancer Consortium (DKTK), German Cancer Research Center(DKFZ), Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Elke Pfaff
- Division of Pediatric Neuro-oncology, DKFZ, German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.,Department of Pediatric Oncology, Hematology, Immunology, and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Benedikt Brors
- Division of Applied Bioinformatics, DKFZ, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany.,DKTK
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, DKFZ, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany.,DKFZ, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Christel Herold-Mende
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Eisenmenger
- NCT Trial Center, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, DKTK
| | - David T W Jones
- Division of Pediatric Neuro-oncology, DKFZ, German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Stefan M Pfister
- Division of Pediatric Neuro-oncology, DKFZ, German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.,Department of Pediatric Oncology, Hematology, Immunology, and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, DKTK
| | - Michael Platten
- Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, DKTK, DKFZ, Heidelberg, Germany.,Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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20
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Berberich A, Schneider C, Herweh C, Hielscher T, Reiff T, Bendszus M, Gumbinger C, Ringleb P. Risk factors associated with progressive lacunar strokes and benefit from dual antiplatelet therapy. Eur J Neurol 2020; 27:817-824. [PMID: 31994783 DOI: 10.1111/ene.14159] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Early neurological deterioration (END) occurs in 20%-30% of patients with lacunar stroke and challenges their clinical management. This retrospective cohort study analyzed clinical and neuroimaging risk factors predicting the occurrence of END, the functional outcome after END and potential benefit from dual antiplatelet therapy (DAPT) in patients with lacunar strokes. METHODS Factors associated with END and benefit from DAPT were retrospectively analyzed in 308 patients with lacunar stroke symptoms and detected lacunar infarction by magnetic resonance imaging. END was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale (NIHSS) points, ≥2 NIHSS points for limb paresis or documented deterioration within 5 days after admission. Patients were treated with DAPT according to in-house standards. The primary efficacy end-point for functional outcome was fulfilled if NIHSS at discharge improved after END at least to the score at admission. RESULTS Male gender [odds ratio (OR) 2.08; 95% confidence interval (CI) 1.09-4.00], higher age (OR = 1.65 per 10 years; 95% CI 1.18-2.31), motor paresis (OR = 18.89, 95% CI 4.66-76.57) and infarction of the internal capsule or basal ganglia (OR = 3.58, 95% CI 1.26-10.14) were associated with an increased risk for END. A larger diameter of infarction (OR = 0.85, 95% CI 0.76-0.95), more microangiopathic lesions (OR = 0.75, 95% CI 0.57-0.99) and pontine localization (OR = 0.29, 95% CI 0.12-0.65) were factors associated with unfavorable functional outcome after END occurred. Localization in the internal capsule or basal ganglia was identified as a significant predictive factor for a benefit from DAPT after END. CONCLUSIONS Identified clinical and neuroimaging factors predicting END occurrence, functional outcome after END and potential benefit from DAPT might improve the clinical management of patients with lacunar strokes.
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Affiliation(s)
- A Berberich
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Schneider
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - T Hielscher
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - T Reiff
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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21
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Kessler T, Berberich A, Casalini B, Drüschler K, Ostermann H, Dormann A, Walter S, Hai L, Schlesner M, Herold-Mende C, Jungk C, Unterberg A, Bendszus M, Sahm K, von Deimling A, Winkler F, Platten M, Wick W, Sahm F, Wick A. Molecular profiling-based decision for targeted therapies in IDH wild-type glioblastoma. Neurooncol Adv 2020; 2:vdz060. [PMID: 32642725 PMCID: PMC7212885 DOI: 10.1093/noajnl/vdz060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Indexed: 12/22/2022] Open
Abstract
Background Molecular profiling allows tumor classification as well as assessment of diagnostic, prognostic, and treatment-related molecular changes. Translation into clinical practice and relevance for patients has not been demonstrated yet. Methods We analyzed clinical and molecular data of isocitrate dehydrogenase wild-type glioblastoma patients with sufficient clinical follow-up from the Heidelberg Neuro-Oncology Center and with molecular analysis of tumor tissue that consisted of DNA methylation array data, genome-scale copy number variations, gene panel sequencing, and partly mTOR immunohistochemistry between October 2014 and April 2018. Results Of 536 patients screened, molecular assessment was performed in 253 patients (47%) in a prospective routine clinical setting with further clinical appointments. Therapy decision was directly based on the molecular assessment in 97 (38%) patients. Of these, genetic information from MGMT (n = 68), EGFR (n = 7), CDKN2A/B (n = 8), alterations of the PI3K–AKT–mTOR pathway (n = 5), and BRAF (n = 3) have been the most frequently used for decision making with a positive overall survival signal for patients with glioblastoma harboring an unmethylated MGMT promoter treated according to the molecular assignment. Based on detected molecular alterations and possible targeted therapies, we generated an automated web-based prioritization algorithm. Conclusion Molecular decision making in clinical practice was mainly driven by MGMT promoter status in elderly patients and study inclusion criteria. A reasonable number of patients have been treated based on other molecular aberrations. This study prepares for complex molecular decisions in a routine clinical decision making.
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Affiliation(s)
- Tobias Kessler
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Anne Berberich
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Belen Casalini
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Katharina Drüschler
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Hannah Ostermann
- Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea Dormann
- Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Sandy Walter
- Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Ling Hai
- Junior Research Group Bioinformatics and Omics Data Analytics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Matthias Schlesner
- Junior Research Group Bioinformatics and Omics Data Analytics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Christine Jungk
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Sahm
- Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Frank Winkler
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Platten
- Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Antje Wick
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
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22
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Berberich A, Schneider C, Reiff T, Gumbinger C, Ringleb PA. Dual Antiplatelet Therapy Improves Functional Outcome in Patients With Progressive Lacunar Strokes. Stroke 2020; 50:1007-1009. [PMID: 30841818 DOI: 10.1161/strokeaha.118.023789] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [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- In 20% to 30% of patients with lacunar strokes, early neurological deterioration (END) occurs within the first days after stroke onset. However, effective treatment strategies are still missing for these patients. The purpose of this study was to analyze efficacy of dual antiplatelet therapy (DAPT) in patients presenting with END. Methods- Four hundred fifty-eight patients with lacunar strokes and corresponding neuroimaging evidence of lacunar ischemia were retrospectively screened for END, which was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale points, ≥2 National Institutes of Health Stroke Scale points for limb paresis, or documented clinical deterioration within 5 days after admission. Patients with END were treated with DAPT according to in-house standards. Primary efficacy end point was fulfilled if National Institutes of Health Stroke Scale score at discharge improved at least to the score at admission. Secondary end points were Rankin Scale score, further clinical fluctuation, and symptomatic bleeding complications. Results- END occurred in 130 (28%) of 458 patients with lacunar strokes. Ninety-seven (75%) of these patients were treated with DAPT after END, mostly for 5 days. DAPT was associated with improved functional outcome. The primary end point was met in 68% (66) of patients with DAPT compared with 36% (12) of patients with standard treatment ( P=0.0019). Further clinical fluctuations were absent in 79% (77) of patients with DAPT versus 33% (11) of patients without DAPT ( P<0.001). Symptomatic bleeding complications were not observed in any patient. Conclusions- The results demonstrated potential positive effects of DAPT in patients with progressive lacunar strokes.
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Affiliation(s)
- Anne Berberich
- From the Department of Neurology, Heidelberg University Hospital, Germany
| | | | - Tilman Reiff
- From the Department of Neurology, Heidelberg University Hospital, Germany
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Berberich A, Bartels F, Tang Z, Pusch S, Hucke N, Kessler T, Dong Z, Wiestler B, Winkler F, Platten M, Wick W, Abdollahi A, Lemke D. P11.07 LAPTM5 functions as a tumor suppressor via CD40 - NFêB pathway inhibition and represents a potential biomarker for temozolomide sensitivity in CD40 proficient glioblastoma. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz126.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Glioma therapy is challenged by the invasive nature of glioma resulting in tumor recurrence and treatment resistance. Lysosomal protein transmembrane 5 (LAPTM5) was identified to inhibit invasion by screening for invasion-associated genes in glioma. The aim of this study was to decipher the function of LAPTM5 in glioblastoma and its interaction with the CD40 receptor which was shown to be highly expressed in up to 40% of glioblastoma.
METHODS
LAPTM5 expression was correlated with clinical outcome of glioma patients. Knockdown of LAPTM5 was performed in different glioma cell lines to analyze the impact on clonogenicity, invasiveness, sensitivity to temozolomide chemotherapy and tumorigenicity in-vitro and in-vivo in a subcutaneous xenograft mouse model. Expression array was used to elucidate the underlying pathways. CD40 knockdown and overexpression was induced to prove the crosstalk of LAPTM5 and CD40.
RESULTS
LAPTM5 expression correlated with better overall survival in high grade glioma patients and acted as a tumor suppressor in CD40 positive glioblastoma cells. LAPTM5 inhibited CD40-mediated NFκB activation resulting in anti-invasive, anti-clonogenic and temozolomide sensitizing effects in-vitro and in-vivo. Vice-versa, knockdown of LAPTM5 enhanced tumorigenicity by activation of the NFκB pathway which was overcome by NFκB inhibition. Importantly, CD40 expression was required for LAPTM5-mediated tumor suppressive activity.
CONCLUSION
LAPTM5 conveyed tumor suppressive and temozolomide sensitizing effects in CD40-positive glioblastoma by inhibition of CD40-mediated NFκB activation and thereby might provide a reasonable biomarker for sensitivity to temozolomide in CD40-positive glioblastoma.
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Affiliation(s)
- A Berberich
- German Cancer Research Center, Heidelberg, Germany
- Department of Neurology, University Hospital, Heidelberg, Germany
| | - F Bartels
- German Cancer Research Center, Heidelberg, Germany
- Department of Neurology, University Hospital, Heidelberg, Germany
| | - Z Tang
- German Cancer Research Center, Heidelberg, Germany
- Division of Molecular& Translational Radiation Oncology, University Hospital, Heidelberg, Germany
| | - S Pusch
- German Cancer Research Center, Heidelberg, Germany
| | - N Hucke
- German Cancer Research Center, Heidelberg, Germany
| | - T Kessler
- German Cancer Research Center, Heidelberg, Germany
- Department of Neurology, University Hospital, Heidelberg, Germany
| | - Z Dong
- Tongji Hospital, Department of Neurosurgery, Wuhan, China
| | - B Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar der Technischen Universität, München, Germany
| | - F Winkler
- German Cancer Research Center, Heidelberg, Germany
- Department of Neurology, University Hospital, Heidelberg, Germany
| | - M Platten
- German Cancer Research Center, Heidelberg, Germany
- Department of Neurology, Medical Faculty Mannheim, Mannheim, Germany
| | - W Wick
- German Cancer Research Center, Heidelberg, Germany
- Department of Neurology, University Hospital, Heidelberg, Germany
| | - A Abdollahi
- German Cancer Research Center, Heidelberg, Germany
- Division of Molecular& Translational Radiation Oncology, University Hospital, Heidelberg, Germany
| | - D Lemke
- German Cancer Research Center, Heidelberg, Germany
- Department of Neurology, University Hospital, Heidelberg, Germany
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24
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Berberich A, Gumbinger C, Ringleb PA. Response by Berberich et al to Letters Regarding Article, “Dual Antiplatelet Therapy Improves Functional Outcome in Patients With Progressive Lacunar Strokes”. Stroke 2019; 50:e216. [DOI: 10.1161/strokeaha.119.026007] [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: 11/16/2022]
Affiliation(s)
- Anne Berberich
- Department of Neurology, Heidelberg University Hospital, Germany
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25
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Pfaff E, Kessler T, Balasubramanian GP, Berberich A, Schrimpf D, Wick A, Debus J, Unterberg A, Bendszus M, Herold-Mende C, Capper D, Schenkel I, Eisenmenger A, Dettmer S, Brors B, Platten M, Pfister SM, von Deimling A, Jones DTW, Wick W, Sahm F. Feasibility of real-time molecular profiling for patients with newly diagnosed glioblastoma without MGMT promoter hypermethylation-the NCT Neuro Master Match (N2M2) pilot study. Neuro Oncol 2019; 20:826-837. [PMID: 29165638 DOI: 10.1093/neuonc/nox216] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status is a predictive biomarker in glioblastoma patients. Glioblastoma without hypermethylated MGMT promoter is largely resistant to treatment with temozolomide. These patients are in particular need of new treatment approaches, which are offered by biomarker-driven clinical trials with targeted drugs based on molecular characterization of individual tumors. Methods In preparation for an upcoming clinical study, a comprehensive molecular profiling approach was undertaken on tissues from 43 glioblastoma patients harboring an unmethylated MGMT promoter at diagnosis. The diagnostic pipeline covered various levels of molecular characteristics, including whole-exome sequencing, low-coverage whole-genome sequencing, RNA sequencing, as well as microarray-based gene expression profiling and DNA methylation arrays. Results Complex multilayer molecular diagnostics were feasible in this setting with a median turnaround time of 4-5 weeks from surgery to the molecular tumor board. In 35% of cases, potentially relevant therapeutic decisions were derived from the data. Alterations were most frequently found in receptor tyrosine kinases, members of the phosphoinositide 3-kinase/Akt/mechanistic target of rapamycin and mitogen-activated protein kinase pathway as well as cell cycle control and p53 regulation cascades. Individual tumors harbored clonal alterations such as oncogenic fusions of tyrosine kinases which constitute promising targets for targeted therapies. A prioritization algorithm is proposed to allocate patients with multiple targets to the potentially best treatment option. Conclusion With this feasibility study, a comprehensive molecular profiling approach for patients with newly diagnosed glioblastoma harboring an unmethylated MGMT promoter is presented. Analyses in this pilot cohort serve as a basis for trials based on targetable alterations and on the question of allocation of patients to the best treatment arm.
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Affiliation(s)
- Elke Pfaff
- Division of Pediatric Neuro-oncology, German Cancer Research Center (DKFZ), German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.,Department of Pediatric Oncology, Hematology, Immunology, and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Kessler
- Clinical Cooperation Unit Neuro-oncology, DKTK, DKFZ, Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Heidelberg, Germany
| | - Gnana Prakash Balasubramanian
- Division of Pediatric Neuro-oncology, German Cancer Research Center (DKFZ), German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.,Division of Applied Bioinformatics, DKFZ, Heidelberg, Germany.,National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Anne Berberich
- Clinical Cooperation Unit Neuro-oncology, DKTK, DKFZ, Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Heidelberg, Germany
| | - Daniel Schrimpf
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, DKTK, DKFZ, Heidelberg, Germany
| | - Antje Wick
- Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, DKFZ, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Christel Herold-Mende
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - David Capper
- Department of Neuropathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Irini Schenkel
- NCT Trial Center, National Center for Tumor Diseases, DKFZ, Heidelberg, Germany
| | - Andreas Eisenmenger
- NCT Trial Center, National Center for Tumor Diseases, DKFZ, Heidelberg, Germany
| | - Susan Dettmer
- NCT Trial Center, National Center for Tumor Diseases, DKFZ, Heidelberg, Germany
| | - Benedikt Brors
- Division of Applied Bioinformatics, DKFZ, Heidelberg, Germany.,National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany.,DKTK, Heidelberg, Germany
| | - Michael Platten
- Clinical Cooperation Unit Neuroimmunology and Brain Tumor Immunology, DKTK, DKFZ, Heidelberg, Germany.,Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan M Pfister
- Division of Pediatric Neuro-oncology, German Cancer Research Center (DKFZ), German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.,Department of Pediatric Oncology, Hematology, Immunology, and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, DKTK, DKFZ, Heidelberg, Germany
| | - David T W Jones
- Division of Pediatric Neuro-oncology, German Cancer Research Center (DKFZ), German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit Neuro-oncology, DKTK, DKFZ, Heidelberg, Germany.,Department of Neurology and Neuro-oncology Program, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Neuropathology, DKTK, DKFZ, Heidelberg, Germany
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Berberich A, Kessler T, Thomé CM, Pusch S, Hielscher T, Sahm F, Oezen I, Schmitt LM, Ciprut S, Hucke N, Ruebmann P, Fischer M, Lemke D, Breckwoldt MO, von Deimling A, Bendszus M, Platten M, Wick W. Targeting Resistance against the MDM2 Inhibitor RG7388 in Glioblastoma Cells by the MEK Inhibitor Trametinib. Clin Cancer Res 2018; 25:253-265. [DOI: 10.1158/1078-0432.ccr-18-1580] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/07/2018] [Accepted: 09/27/2018] [Indexed: 11/16/2022]
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Berberich A. P01.022 Non-measurable speckled contrast-enhancing lesions appearing during course of disease are associated with IDH mutation in high-grade astrocytoma patients. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy139.064] [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: 11/12/2022] Open
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28
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Berberich A, Hielscher T, Kickingereder P, Winkler F, Drüschler K, Riedemann L, Arzt M, Kessler T, Platten M, von Deimling A, Wick W, Sahm F, Bendszus M, Wick A. Nonmeasurable Speckled Contrast-Enhancing Lesions Appearing During Course of Disease Are Associated With IDH Mutation in High-Grade Astrocytoma Patients. Int J Radiat Oncol Biol Phys 2018; 102:1472-1480. [PMID: 30071292 DOI: 10.1016/j.ijrobp.2018.07.2004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 03/05/2018] [Revised: 07/17/2018] [Accepted: 07/21/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE Because treatment options at progression are limited for patients with glioma, accuracy in definition of progression is pivotal. Clinically asymptomatic, newly detected, nonmeasurable, speckled contrast-enhancing lesions (SCEs) without immediate relation to prior immune therapy or radiation therapy appear relatively frequently during the course of disease in patients with glioma and challenge the definition of progression based on Response Assessment in Neuro-oncology criteria. Therefore, data characterizing these SCEs are needed for recommendations of subsequent clinical management. MATERIALS AND METHODS Magnetic resonance imaging of 746 patients with glioma included in this study were retrospectively revised for appearance of newly detected SCEs during the course of disease. Associations with molecular and clinical baseline parameters and their prognostic impact were statistically analyzed, and frequency, natural course, and location of SCEs were described. RESULTS SCEs occurred more frequently in World Health Organization grade 2 and 3 astrocytoma and oligodendroglial tumors and were significantly associated with isocitrate dehydrogenase mutation in World Health Organization grade 3 astrocytoma and glioblastoma. SCEs mostly remained stable or dissolved in follow-up magnetic resonance imaging, even if no new treatment was initiated. SCEs were frequently located within the tumor or tumor-associated fluid-attenuated inversion recovery abnormalities, but distant appearance also occurred. In patients with glioblastoma, SCEs were associated with a favorable prognosis, which was also observed in the subgroup of patients with glioblastoma with isocitrate dehydrogenase wildtype status. CONCLUSIONS The data demonstrate a predominantly benign course of SCEs after their appearance and emphasize cautious definitions of progression and regular clinical and radiographic follow-up rather than premature initiation of new antitumor therapies until progression is confirmed.
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Affiliation(s)
- Anne Berberich
- Clinical Cooperation Unit, Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Frank Winkler
- Clinical Cooperation Unit, Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Katharina Drüschler
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Lars Riedemann
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Marlene Arzt
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Kessler
- Clinical Cooperation Unit, Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Platten
- Clinical Cooperation Unit, Neuroimmunology and Brain Tumor Immunology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Wick
- Clinical Cooperation Unit, Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany; Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Antje Wick
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany.
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Kessler T, Sahm F, Balasubramanian GP, Pfaff E, Jones DTW, Wick A, Debus J, Unterberg A, Berberich A, Herold-Mende C, Pfister SM, Brors B, Dettmer S, Karapanagiotou-Schenkel I, Winkler F, Bendszus M, von Deimling A, Platten M, Wick W. Towards a molecular algorithm predicting glioma treatment response and resistance: A biomarker analysis and path to real time profiling in N 2M 2. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.12090] [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: 11/20/2022] Open
Affiliation(s)
| | - Felix Sahm
- Heidelberg University Hospital, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Elke Pfaff
- Hopp Children’s Cancer Center at NCT Heidelberg (KiTZ), Heidelberg, Germany
| | - David T. W. Jones
- German Cancer Research Center (DKFZ), University Hospital Heidelberg, and German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Antje Wick
- Neurology Clinic, University of Heidelberg, National Center for Tumor Diseases, Heidelberg, Germany
| | | | | | - Anne Berberich
- Heidelberg University Hospital, German Cancer Research Center (DKFZ), Heidelberg, DE, Germany
| | | | - Stefan M. Pfister
- Division of Pediatric Neurooncology, Hopp Children’s Cancer Center at the NCT Heidelberg (KiTZ), German Cancer Research Center (DKFZ) and Heidelberg University Hospital, Heidelberg, Germany
| | - Benedikt Brors
- Division of Applied Bioinformatics, German Cancer Research Center, Heidelberg, Germany
| | - Susan Dettmer
- NCT Trial Center, German Cancer Research Center, Heidelberg, Germany
| | | | - Frank Winkler
- Deparment of Neurology, University Hospital Heidelberg and National Center of Tumor Diseases, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Institute of Pathology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
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Abstract
Paratonsillar abscesses are preferably treated by abscess tonsillectomy as operative therapy. The casuistry of a patient aged 17 who was tonsillectomized for a paratonsillar abscess and died after 12 days prompted a discussion on the scope of preoperative diagnostics. The clinical examination and anamnesis of the young man prior to the operation did not give evidence of any concomitant diseases. It was only through extensive microscopic investigations of the myocardium after autopsy that inflammatory infiltrates of the epicardium, endocardium and myocardium in the vicinity of portions of the conduction system were detected. The relevance of autopsy to the quality assurance in clinical activities is emphasized. Legal questions of possible negligent homicide as a result of the failure to take diagnostic and therapeutic measures are raised.
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Affiliation(s)
- J Dressler
- Universitätsklinikum der Technischen Universität Dresden, Institut für Rechtsmedizin.
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31
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Affiliation(s)
- C Offergeld
- Klinik und Poliklinik für Hals-Nasen- und Ohren-Heilkunde, TU Dresden.
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Berberich A, Hüttenbrink KB. [Recurrent meningitis in cleft lip-palate. Sphenopharyngeal meningocele]. HNO 1998; 46:346-7. [PMID: 9606649 DOI: 10.1007/s001060050250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- A Berberich
- Klinik und Poliklinik für HNO-Heilkunde, Universitätsklinik Carl Gustav Carus der TU Dresden
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