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Hill MD, Gill SS, Le-Niculescu H, MacKie O, Bhagar R, Roseberry K, Murray OK, Dainton HD, Wolf SK, Shekhar A, Kurian SM, Niculescu AB. Precision medicine for psychotic disorders: objective assessment, risk prediction, and pharmacogenomics. Mol Psychiatry 2024:10.1038/s41380-024-02433-8. [PMID: 38326562 DOI: 10.1038/s41380-024-02433-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/16/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024]
Abstract
Psychosis occurs inside the brain, but may have external manifestations (peripheral molecular biomarkers, behaviors) that can be objectively and quantitatively measured. Blood biomarkers that track core psychotic manifestations such as hallucinations and delusions could provide a window into the biology of psychosis, as well as help with diagnosis and treatment. We endeavored to identify objective blood gene expression biomarkers for hallucinations and delusions, using a stepwise discovery, prioritization, validation, and testing in independent cohorts design. We were successful in identifying biomarkers that were predictive of high hallucinations and of high delusions states, and of future psychiatric hospitalizations related to them, more so when personalized by gender and diagnosis. Top biomarkers for hallucinations that survived discovery, prioritization, validation and testing include PPP3CB, DLG1, ENPP2, ZEB2, and RTN4. Top biomarkers for delusions include AUTS2, MACROD2, NR4A2, PDE4D, PDP1, and RORA. The top biological pathways uncovered by our work are glutamatergic synapse for hallucinations, as well as Rap1 signaling for delusions. Some of the biomarkers are targets of existing drugs, of potential utility in pharmacogenomics approaches (matching patients to medications, monitoring response to treatment). The top biomarkers gene expression signatures through bioinformatic analyses suggested a prioritization of existing medications such as clozapine and risperidone, as well as of lithium, fluoxetine, valproate, and the nutraceuticals omega-3 fatty acids and magnesium. Finally, we provide an example of how a personalized laboratory report for doctors would look. Overall, our work provides advances for the improved diagnosis and treatment for schizophrenia and other psychotic disorders.
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Affiliation(s)
- M D Hill
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Indianapolis VA Medical Center, Indianapolis, IN, USA
| | - S S Gill
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - H Le-Niculescu
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Stark Neuroscience Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - O MacKie
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Indianapolis VA Medical Center, Indianapolis, IN, USA
| | - R Bhagar
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - K Roseberry
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - O K Murray
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - H D Dainton
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - S K Wolf
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Neurology, Ohio State University Medical Center, Columbus, OH, USA
| | - A Shekhar
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Office of the Dean, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - A B Niculescu
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA.
- Indianapolis VA Medical Center, Indianapolis, IN, USA.
- Stark Neuroscience Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA.
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Rex NB, McDonough RV, Ospel JM, Kashani N, Sehgal A, Fladt JC, McTaggart RA, Nogueira R, Menon B, Demchuk AM, Tymianski M, Hill MD, Goyal M. CT Perfusion Does Not Modify the Effect of Reperfusion in Patients with Acute Ischemic Stroke Undergoing Endovascular Treatment in the ESCAPE-NA1 Trial. AJNR Am J Neuroradiol 2023; 44:1045-1049. [PMID: 37620153 PMCID: PMC10494951 DOI: 10.3174/ajnr.a7954] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/27/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND AND PURPOSE Although reperfusion is associated with improved outcomes in patients with acute ischemic stroke undergoing endovascular treatment, many patients still do poorly. We investigated whether CTP modifies the effect of near-complete reperfusion on clinical outcomes, ie, whether poor clinical outcomes despite near-complete reperfusion can be partly or fully explained by CTP findings. MATERIALS AND METHODS Data are from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial. Admission CTP was processed using RAPID software, generating relative CBF and CBV volume maps at standard thresholds. CTP lesion volumes were compared in patients with-versus-without near-complete reperfusion. Associations between each CTP metric and clinical outcome (90-day mRS) were tested using multivariable logistic regression, adjusted for baseline imaging and clinical variables. Treatment-effect modification was assessed by introducing CTP lesion volume × reperfusion interaction terms in the models. RESULTS CTP lesion volumes and reperfusion status were available in 410/1105 patients. CTP lesion volumes were overall larger in patients without near-complete reperfusion, albeit not always statistically significant. Increased CBF <34%, CBV <34%, CBV <38%, and CBV <42% lesion volumes were associated with worse clinical outcome (ordinal mRS) at 90 days. CTP core lesion volumes did not modify the treatment effect of near-complete recanalization on clinical outcome. CONCLUSIONS CTP did not modify the effect of near-complete reperfusion on clinical outcomes. Thus, CTP cannot explain why some patients with near-complete reperfusion have poor clinical outcomes.
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Affiliation(s)
- N B Rex
- From the Department of Diagnostic Imaging (N.B.R., R.A.M.), Brown University, Providence, Rhode Island
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - R V McDonough
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - J M Ospel
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - N Kashani
- Department of Neurosurgery (N.K.), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - A Sehgal
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - J C Fladt
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Neurology and Stroke Center (J.C.F.), University Hospital Basel, Basel, Switzerland
| | - R A McTaggart
- From the Department of Diagnostic Imaging (N.B.R., R.A.M.), Brown University, Providence, Rhode Island
| | - R Nogueira
- Department of Neurology and Neurosurgery (R.N.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - B Menon
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | | | - M D Hill
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
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Zhu K, Bala F, Zhang J, Benali F, Cimflova P, Kim BJ, McDonough R, Singh N, Hill MD, Goyal M, Demchuk A, Menon BK, Qiu W. Automated Segmentation of Intracranial Thrombus on NCCT and CTA in Patients with Acute Ischemic Stroke Using a Coarse-to-Fine Deep Learning Model. AJNR Am J Neuroradiol 2023; 44:641-648. [PMID: 37202113 PMCID: PMC10249699 DOI: 10.3174/ajnr.a7878] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/20/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND PURPOSE Identifying the presence and extent of intracranial thrombi is crucial in selecting patients with acute ischemic stroke for treatment. This article aims to develop an automated approach to quantify thrombus on NCCT and CTA in patients with stroke. MATERIALS AND METHODS A total of 499 patients with large-vessel occlusion from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial were included. All patients had thin-section NCCT and CTA images. Thrombi contoured manually were used as reference standard. A deep learning approach was developed to segment thrombi automatically. Of 499 patients, 263 and 66 patients were randomly selected to train and validate the deep learning model, respectively; the remaining 170 patients were independently used for testing. The deep learning model was quantitatively compared with the reference standard using the Dice coefficient and volumetric error. The proposed deep learning model was externally tested on 83 patients with and without large-vessel occlusion from another independent trial. RESULTS The developed deep learning approach obtained a Dice coefficient of 70.7% (interquartile range, 58.0%-77.8%) in the internal cohort. The predicted thrombi length and volume were correlated with those of expert-contoured thrombi (r = 0.88 and 0.87, respectively; P < .001). When the derived deep learning model was applied to the external data set, the model obtained similar results in patients with large-vessel occlusion regarding the Dice coefficient (66.8%; interquartile range, 58.5%-74.6%), thrombus length (r = 0.73), and volume (r = 0.80). The model also obtained a sensitivity of 94.12% (32/34) and a specificity of 97.96% (48/49) in classifying large-vessel occlusion versus non-large-vessel occlusion. CONCLUSIONS The proposed deep learning method can reliably detect and measure thrombi on NCCT and CTA in patients with acute ischemic stroke.
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Affiliation(s)
- K Zhu
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
- College of Electronic Engineering (K.Z.), Xi'an Shiyou University, Xi'an, Shaanxi, China
| | - F Bala
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
| | - J Zhang
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
| | - F Benali
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
| | - P Cimflova
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
- Department of Medicine, and Department of Radiology (P.C., M.D.H., A.D.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- St. Anne's University Hospital Brno and Faculty of Medicine (P.C.), Masaryk University, Brno, Czech Republic
| | - B J Kim
- Department of Neurology and Cerebrovascular Center (B.J.K.), Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - R McDonough
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
- Department of Diagnostic and Interventional Neuroradiology (R.M.), University Hospital Hamburg, Hamburg, Germany
| | - N Singh
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
| | - M D Hill
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
- Department of Community Health Sciences (M.D.H.)
- Department of Medicine, and Department of Radiology (P.C., M.D.H., A.D.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
| | - A Demchuk
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
- Department of Medicine, and Department of Radiology (P.C., M.D.H., A.D.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (K.Z., F. Bala, J.Z., F. Benali, P.C., R.M., N.S., M.D.H., M.G., A.D., B.K.M.)
| | - W Qiu
- School of Life Science and Technology (W.Q.), Huazhong University of Science and Technology, Wuhan, Hubei, China
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Bala F, Kim BJ, Najm M, Thornton J, Fainardi E, Michel P, Alpay K, Herlihy D, Goyal M, Casetta I, Nannoni S, Ylikotila P, Power S, Saia V, Hegarty A, Pracucci G, Rautio R, Ademola A, Demchuk A, Mangiafico S, Boyle K, Hill MD, Toni D, Murphy S, Menon BK, Almekhlafi MA. Outcomes with Endovascular Treatment of Patients with M2 Segment MCA Occlusion in the Late Time Window. AJNR Am J Neuroradiol 2023; 44:447-452. [PMID: 36958801 PMCID: PMC10084904 DOI: 10.3174/ajnr.a7833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/23/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Randomized trials in the late window have demonstrated the efficacy and safety of endovascular thrombectomy in large-vessel occlusions. Patients with M2-segment MCA occlusions were excluded from these trials. We compared outcomes with endovascular thrombectomy in patients with M2-versus-M1 occlusions presenting 6-24 hours after symptom onset. MATERIALS AND METHODS Analyses were on pooled data from studies enrolling patients with stroke treated with endovascular thrombectomy 6-24 hours after symptom onset. We compared 90-day functional independence (mRS ≤ 2), mortality, symptomatic intracranial hemorrhage, and successful reperfusion (expanded TICI = 2b-3) between patients with M2 and M1 occlusions. The benefit of successful reperfusion was then assessed among patients with M2 occlusion. RESULTS Of 461 patients, 367 (79.6%) had M1 occlusions and 94 (20.4%) had M2 occlusions. Patients with M2 occlusions were older and had lower median baseline NIHSS scores. Patients with M2 occlusion were more likely to achieve 90-day functional independence than those with M1 occlusion (adjusted OR = 2.13; 95% CI, 1.25-3.65). There were no significant differences in the proportion of successful reperfusion (82.9% versus 81.1%) or mortality (11.2% versus 17.2%). Symptomatic intracranial hemorrhage risk was lower in patients with M2-versus-M1 occlusions (4.3% versus 12.2%, P = .03). Successful reperfusion was independently associated with functional independence among patients with M2 occlusions (adjusted OR = 2.84; 95% CI, 1.11-7.29). CONCLUSIONS In the late time window, patients with M2 occlusions treated with endovascular thrombectomy achieved better clinical outcomes, similar reperfusion, and lower symptomatic intracranial hemorrhage rates compared with patients with M1 occlusion. These results support the safety and benefit of endovascular thrombectomy in patients with M2 occlusions in the late window.
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Affiliation(s)
- F Bala
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Diagnostic and Interventional Neuroradiology Department (F.B.), University Hospital of Tours, Tours, France
| | - B J Kim
- Department of Neurology and Cerebrovascular Center (B.J.K.), Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - M Najm
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - J Thornton
- Neuroradiology Department (J.T., D.H., S.P.)
- Royal College of Surgeons in Ireland (J.T., A.H.), Dublin, Ireland
| | - E Fainardi
- Neuroradiology Unit (E.F.), Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - P Michel
- Stroke Center (P.M., S.N.), Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - K Alpay
- Department of Radiology (K.A., R.R.), Turku University Hospital, Turku, Finland
| | - D Herlihy
- Neuroradiology Department (J.T., D.H., S.P.)
| | - M Goyal
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - I Casetta
- Clinica Neurologica (I.C.), University of Ferrara, Ferrara, Italy
| | - S Nannoni
- Stroke Center (P.M., S.N.), Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - P Ylikotila
- Neurocenter (P.Y.), Turku University Hospital, University of Turku, Turku, Finland
| | - S Power
- Neuroradiology Department (J.T., D.H., S.P.)
| | - V Saia
- Stroke Unit (V.S.), Santa Corona Hospital, Pietra Ligure, Italy
| | - A Hegarty
- Royal College of Surgeons in Ireland (J.T., A.H.), Dublin, Ireland
| | - G Pracucci
- Stroke Unit (G.P.), Careggi University Hospital, Florence, Italy
| | - R Rautio
- Department of Radiology (K.A., R.R.), Turku University Hospital, Turku, Finland
| | - A Ademola
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - A Demchuk
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
| | - S Mangiafico
- Interventional Neuroradiology Unit (S. Mangiafico), Institute for Hospitalization and Healthcare Neuromed, Pozzilli, Italy
| | - K Boyle
- Department of Geriatric and Stroke Medicine (K.B.), Beaumont Hospital, Dublin, Ireland
| | - M D Hill
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - D Toni
- Emergency Department (D.T.), Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - S Murphy
- Department of Geriatric and Stroke Medicine (S. Murphy), The Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine (S. Murphy), Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine (S. Murphy), University College Dublin, Dublin, Ireland
| | - B K Menon
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - M A Almekhlafi
- From the Calgary Stroke Program (F.B., M.N., M.G., A.D., M.D.H., B.K.M., M.A.A.), Departments of Clinical Neurosciences and Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (A.A., M.D.H., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
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Mrklas KJ, Boyd JM, Shergill S, Merali S, Khan M, Nowell L, Goertzen A, Pfadenhauer LM, Paul K, Sibley KM, Swain L, Vis-Dunbar M, Hill MD, Raffin-Bouchal S, Tonelli M, Graham ID. Tools for assessing health research partnership outcomes and impacts: a systematic review. Health Res Policy Syst 2023; 21:3. [PMID: 36604697 PMCID: PMC9817421 DOI: 10.1186/s12961-022-00937-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 11/08/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To identify and assess the globally available valid, reliable and acceptable tools for assessing health research partnership outcomes and impacts. METHODS We searched Ovid MEDLINE, Embase, CINAHL Plus and PsycINFO from origin to 2 June 2021, without limits, using an a priori strategy and registered protocol. We screened citations independently and in duplicate, resolving discrepancies by consensus and retaining studies involving health research partnerships, the development, use and/or assessment of tools to evaluate partnership outcomes and impacts, and reporting empirical psychometric evidence. Study, tool, psychometric and pragmatic characteristics were abstracted using a hybrid approach, then synthesized using descriptive statistics and thematic analysis. Study quality was assessed using the quality of survey studies in psychology (Q-SSP) checklist. RESULTS From 56 123 total citations, we screened 36 027 citations, assessed 2784 full-text papers, abstracted data from 48 studies and one companion report, and identified 58 tools. Most tools comprised surveys, questionnaires and scales. Studies used cross-sectional or mixed-method/embedded survey designs and employed quantitative and mixed methods. Both studies and tools were conceptually well grounded, focusing mainly on outcomes, then process, and less frequently on impact measurement. Multiple forms of empirical validity and reliability evidence was present for most tools; however, psychometric characteristics were inconsistently assessed and reported. We identified a subset of studies (22) and accompanying tools distinguished by their empirical psychometric, pragmatic and study quality characteristics. While our review demonstrated psychometric and pragmatic improvements over previous reviews, challenges related to health research partnership assessment and the nascency of partnership science persist. CONCLUSION This systematic review identified multiple tools demonstrating empirical psychometric evidence, pragmatic strength and moderate study quality. Increased attention to psychometric and pragmatic requirements in tool development, testing and reporting is key to advancing health research partnership assessment and partnership science. PROSPERO CRD42021137932.
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Affiliation(s)
- K. J. Mrklas
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
- Strategic Clinical Networks™, Provincial Clinical Excellence, Alberta Health Services, Calgary, AB Canada
| | - J. M. Boyd
- Knowledge Translation Program, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON Canada
| | - S. Shergill
- Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - S. Merali
- Faculty of Kinesiology, University of Calgary, Calgary, AB Canada
| | - M. Khan
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB Canada
| | - L. Nowell
- Faculty of Nursing, University of Calgary, Calgary, AB Canada
| | - A. Goertzen
- Faculty of Science, University of Alberta, Edmonton, AB Canada
| | - L. M. Pfadenhauer
- Institute for Medical Information Processing, Biometry, and Epidemiology–IBE, Ludwig-Maximilian Universität Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - K. Paul
- University of Calgary Summer Studentships Program, Calgary, AB Canada
| | - K. M. Sibley
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB Canada
| | - L. Swain
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
| | - M. Vis-Dunbar
- University of British Columbia - Okanagan, Kelowna, BC Canada
| | - M. D. Hill
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6 Canada
- Departments of Clinical Neurosciences, Medicine and Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | | | - M. Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
- Office of the Vice-President (Research), University of Calgary, Calgary, AB Canada
| | - I. D. Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON Canada
- School of Epidemiology and Public Health & School of Nursing, University of Ottawa, Ottawa, ON Canada
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Ospel JM, Hill MD, Menon BK, Demchuk A, McTaggart R, Nogueira R, Poppe A, Haussen D, Qiu W, Mayank A, Almekhlafi M, Zerna C, Joshi M, Jayaraman M, Roy D, Rempel J, Buck B, Tymianski M, Goyal M. Strength of Association between Infarct Volume and Clinical Outcome Depends on the Magnitude of Infarct Size: Results from the ESCAPE-NA1 Trial. AJNR Am J Neuroradiol 2021; 42:1375-1379. [PMID: 34167959 DOI: 10.3174/ajnr.a7183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/17/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Infarct volume is an important predictor of clinical outcome in acute stroke. We hypothesized that the association of infarct volume and clinical outcome changes with the magnitude of infarct size. MATERIALS AND METHODS Data were derived from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, in which patients with acute stroke with large-vessel occlusion were randomized to endovascular treatment plus either nerinetide or a placebo. Infarct volume was manually segmented on 24-hour noncontrast CT or DWI. The relationship between infarct volume and good outcome, defined as mRS 0-2 at 90 days, was plotted. Patients were categorized on the basis of visual grouping at the curve shoulders of the infarct volume/outcome plot. The relationship between infarct volume and adjusted probability of good outcome was fitted with linear or polynomial functions as appropriate in each group. RESULTS We included 1099 individuals in the study. Median infarct volume at 24 hours was 24.9 mL (interquartile range [IQR] = 6.6-92.2 mL). On the basis of the infarct volume/outcome plot, 4 infarct volume groups were defined (IQR = 0-15 mL, 15.1-70 mL, 70.1-200 mL, >200 mL). Proportions of good outcome in the 4 groups were 359/431 (83.3%), 219/337 (65.0%), 71/201 (35.3%), and 16/130 (12.3%), respectively. In small infarcts (IQR = 0-15 mL), no relationship with outcome was appreciated. In patients with intermediate infarct volume (IQR = 15-200 mL), there was progressive importance of volume as an outcome predictor. In infarcts of > 200 mL, outcomes were overall poor. CONCLUSIONS The relationship between infarct volume and clinical outcome varies nonlinearly with the magnitude of infarct size. Infarct volume was linearly associated with decreased chances of achieving good outcome in patients with moderate-to-large infarcts, but not in those with small infarcts. In very large infarcts, a near-deterministic association with poor outcome was seen.
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Affiliation(s)
- J M Ospel
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (J.M.O.), University Hospital of Basel, Basel, Switzerland
| | - M D Hill
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A Demchuk
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - R McTaggart
- Department of Interventional Radiology (R.M., M. Jayaraman), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - R Nogueira
- Department of Neurology (R.N., D.H.), Emory University School of Medicine, Atlanta, Georgia
| | - A Poppe
- Centre Hospitalier de l'Université de Montréal (A.P., D.R.), Montreal, Quebec, Canada
| | - D Haussen
- Department of Neurology (R.N., D.H.), Emory University School of Medicine, Atlanta, Georgia
| | - W Qiu
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A Mayank
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada.,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - C Zerna
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M Joshi
- Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M Jayaraman
- Department of Interventional Radiology (R.M., M. Jayaraman), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - D Roy
- Centre Hospitalier de l'Université de Montréal (A.P., D.R.), Montreal, Quebec, Canada
| | - J Rempel
- University of Alberta Hospital (J.R., B.B.), Edmonton, Alberta, Canada
| | - B Buck
- University of Alberta Hospital (J.R., B.B.), Edmonton, Alberta, Canada
| | | | - M Goyal
- Department of Clinical Neurosciences (J.M.O., M.D.H., B.K.M., A.D., W.Q., A.M., M.A., C.Z., M.G.), University of Calgary, Calgary, Alberta, Canada .,Department of Radiology (M.D.H., B.K.M., A.D., M.A., M. Joshi, M.G.), University of Calgary, Calgary, Alberta, Canada
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McDougall CC, Chan L, Sachan S, Guo J, Sah RG, Menon BK, Demchuk AM, Hill MD, Forkert ND, d'Esterre CD, Barber PA. Dynamic CTA-Derived Perfusion Maps Predict Final Infarct Volume: The Simple Perfusion Reconstruction Algorithm. AJNR Am J Neuroradiol 2020; 41:2034-2040. [PMID: 33004342 DOI: 10.3174/ajnr.a6783] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Infarct core volume measurement using CTP (CT perfusion) is a mainstay paradigm for stroke treatment decision-making. Yet, there are several downfalls with cine CTP technology that can be overcome by adopting the simple perfusion reconstruction algorithm (SPIRAL) derived from multiphase CTA. We compare SPIRAL with CTP parameters for the prediction of 24-hour infarction. MATERIALS AND METHODS Seventy-two patients had admission NCCT, multiphase CTA, CTP, and 24-hour DWI. All patients had successful/quality reperfusion. Patient-level and cohort-level receiver operator characteristic curves were generated to determine accuracy. A 10-fold cross-validation was performed on the cohort-level data. Infarct core volume was compared for SPIRAL, CTP-time-to-maximum, and final DWI by Bland-Altman analysis. RESULTS When we compared the accuracy in patients with early and late reperfusion for cortical GM and WM, there was no significant difference at the patient level (0.83 versus 0.84, respectively), cohort level (0.82 versus 0.81, respectively), or the cross-validation (0.77 versus 0.74, respectively). In the patient-level receiver operating characteristic analysis, the SPIRAL map had a slightly higher, though nonsignificant (P < .05), average receiver operating characteristic area under the curve (cortical GM/WM, r = 0.82; basal ganglia = 0.79, respectively) than both the CTP-time-to-maximum (cortical GM/WM = 0.82; basal ganglia = 0.78, respectively) and CTP-CBF (cortical GM/WM = 0.74; basal ganglia = 0.78, respectively) parameter maps. The same relationship was observed at the cohort level. The Bland-Altman plot limits of agreement for SPIRAL and time-to-maximum infarct volume were similar compared with 24-hour DWI. CONCLUSIONS We have shown that perfusion maps generated from a temporally sampled helical CTA are an accurate surrogate for infarct core.
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Affiliation(s)
- C C McDougall
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - L Chan
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - S Sachan
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - J Guo
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - R G Sah
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - B K Menon
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - M D Hill
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - N D Forkert
- Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Alberta Children's Hospital Research Institute (N.D.F.), University of Calgary, Calgary, Alberta, Canada
| | - C D d'Esterre
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - P A Barber
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program .,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
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Smaal JA, de Ridder IR, Heshmatollah A, van Zwam WH, Dippel D, Majoie CB, Brown S, Goyal M, Campbell B, Muir KW, Demchuck AM, Davalos A, Jovin TG, Mitchell PJ, White P, Saver JL, Hill MD, Roos YB, van der Lugt A, van Oostenbrugge RJ. Effect of atrial fibrillation on endovascular thrombectomy for acute ischemic stroke. A meta-analysis of individual patient data from six randomised trials: Results from the HERMES collaboration. Eur Stroke J 2020; 5:245-251. [PMID: 33072878 PMCID: PMC7538768 DOI: 10.1177/2396987320923447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background Atrial fibrillation is an important risk factor for ischemic stroke, and is
associated with an increased risk of poor outcome after ischemic stroke.
Endovascular thrombectomy is safe and effective in acute ischemic stroke
patients with large vessel occlusion of the anterior circulation. This
meta-analysis aims to investigate whether there is an interaction between
atrial fibrillation and treatment effect of endovascular thrombectomy, and
secondarily whether atrial fibrillation is associated with worse outcome in
patients with ischemic stroke due to large vessel occlusion. Methods Individual patient data were from six of the recent randomised clinical
trials (MR CLEAN, EXTEND-IA, REVASCAT, SWIFT PRIME, ESCAPE, PISTE) in which
endovascular thrombectomy plus standard care was compared to standard care
alone. Primary outcome measure was the shift on the modified Rankin scale
(mRS) at 90 days. Secondary outcomes were functional independence (mRS 0–2)
at 90 days, National Institutes of Health Stroke Scale score at 24 h,
symptomatic intracranial hemorrhage and mortality at 90 days. The primary
effect parameter was the adjusted common odds ratio, estimated with ordinal
logistic regression (shift analysis); treatment effect modification of
atrial fibrillation was assessed with a multiplicative interaction term. Results Among 1351 patients, 447 patients had atrial fibrillation, 224 of whom were
treated with endovascular thrombectomy. We found no interaction of atrial
fibrillation with treatment effect of endovascular thrombectomy for both
primary (p-value for interaction: 0.58) and secondary
outcomes. Regardless of treatment allocation, we found no difference in
primary outcome (mRS at 90 days: aOR 1.11 (95% CI 0.89–1.38) and secondary
outcomes between patients with and without atrial fibrillation. Conclusion We found no interaction of atrial fibrillation on treatment effect of
endovascular thrombectomy, and no difference in outcome between large vessel
occlusion stroke patients with and without atrial fibrillation.
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Affiliation(s)
- J A Smaal
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - I R de Ridder
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - A Heshmatollah
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - W H van Zwam
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Dwj Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - C B Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - S Brown
- Altair Biostatistics, St Louis Park, MN, USA
| | - M Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Bcv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - K W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - A M Demchuck
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - A Davalos
- Department of Neuroscience, University Autònoma de Barcelona, Spain
| | - T G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - P J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - P White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - J L Saver
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - M D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Y B Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - A van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - R J van Oostenbrugge
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Ospel JM, Kashani N, Fischer U, Menon BK, Almekhlafi M, Wilson AT, Foss MM, Saposnik G, Goyal M, Hill MD. How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT. AJNR Am J Neuroradiol 2020; 41:262-267. [PMID: 31974081 DOI: 10.3174/ajnr.a6396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE With increasing use of endovascular therapy, physicians' attitudes toward intravenous alteplase in endovascular therapy-eligible patients may be changing. We explored current intravenous alteplase treatment practices of physicians in endovascular therapy- and alteplase-eligible patients with acute stroke using prespecified case scenarios and compared how their current local treatment practices differ compared with an assumed ideal environment. MATERIALS AND METHODS In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 of 22 case scenarios, among them 14 with guideline-based alteplase recommendations (9 with level 1A and 5 with level 2B recommendation) and were asked how they would treat the patient: A) under their current local resources, and B) under assumed ideal conditions. Answer options were the following: 1) anticoagulation/antiplatelet therapy, 2) endovascular therapy, 3) endovascular therapy plus intravenous alteplase, and 4) intravenous alteplase. Decision rates were calculated, and multivariable regression analysis was performed to determine variables associated with the decision to abandon intravenous alteplase. RESULTS In cases with guideline recommendations for alteplase, physicians favored alteplase in 82.0% under current local resources and in 79.3% under assumed ideal conditions (P < .001). Under assumed ideal conditions, interventional neuroradiologists would refrain from intravenous alteplase most often (6.28%, OR = 2.40; 95% CI, 1.01-5.71). When physicians' current and ideal decisions differed, most would like to add endovascular therapy to intravenous alteplase in an ideal setting (196/3861 responses, 5.1%). CONCLUSIONS In patients eligible for endovascular therapy and intravenous alteplase, we observed a slightly lower decision rate in favor of intravenous alteplase under assumed ideal conditions compared with the decision rate under current local resources.
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Affiliation(s)
- J M Ospel
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Division of Neuroradiology (J.M.O.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - N Kashani
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - U Fischer
- University Hospital Bern (U.F.), Inselspital, University of Bern, Bern, Switzerland
| | - B K Menon
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - A T Wilson
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
| | - M M Foss
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
| | - G Saposnik
- Division of Neurology (G.S.), Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - M Goyal
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - M D Hill
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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Almekhlafi M, Ospel JM, Saposnik G, Kashani N, Demchuk A, Hill MD, Goyal M, Menon BK. Endovascular Treatment Decisions in Patients with M2 Segment MCA Occlusions. AJNR Am J Neuroradiol 2020; 41:280-285. [PMID: 32001443 DOI: 10.3174/ajnr.a6397] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/09/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy in acute ischemic stroke is rapidly evolving. We explored physicians' treatment attitudes and practice in patients with acute ischemic stroke due to M2 occlusion, given the absence of Level-1 guidelines. MATERIALS AND METHODS We conducted an international multidisciplinary survey among physicians involved in acute stroke care. Respondents were presented with 10 of 22 case scenarios (4 with proximal M2 occlusions and 1 with a small-branch M2 occlusion) and asked about their treatment approach under A) current local resources, and B) assumed ideal conditions (no monetary or infrastructural restraints). Overall treatment decisions were evaluated; subgroup analyses by physician and patient baseline characteristics were performed. RESULTS A total of 607 physicians participated. Most of the respondents decided in favor of endovascular therapy in M2 occlusions, both under current local resources and assumed ideal conditions (65.4% versus 69.6%; P = .017). Under current local resources, older patient age (P < .001), longer time since symptom onset (P < .001), high center endovascular therapy volume (P < .001), high personal endovascular therapy volume (P = .005), and neurosurgeons (P < .001) were more likely to favor endovascular therapy. European respondents were less likely to favor endovascular therapy (P = .001). Under assumed ideal conditions, older patient age (P < .001), longer time since symptom onset (P < .001), high center endovascular therapy volume (P = .041), high personal endovascular therapy volume (P = .002), and Asian respondents were more likely to favor endovascular therapy (P = .037). Respondents with more experience (P = .048) and high annual stroke thrombolysis treatment volume (P = .001) were less likely to favor endovascular therapy. CONCLUSIONS Patients with M2 occlusions are considered appropriate candidates for endovascular therapy by most respondents in this survey, especially by those performing endovascular therapy more often and those practicing in high-volume centers.
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Affiliation(s)
- M Almekhlafi
- From the Department of Clinical Neurosciences (M.A., J.M.O., A.D., M.D.H., M.G., B.K.M.), Hotchkiss Brain Institute.,and Departments of Radiology (M.A., N.K., A.D., M.D.H., M.G., B.K.M.) and.,Community Health Sciences (M.A., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - J M Ospel
- From the Department of Clinical Neurosciences (M.A., J.M.O., A.D., M.D.H., M.G., B.K.M.), Hotchkiss Brain Institute.,Department of Radiology (J.M.O.), University Hospital Basel, University Basel, Basel, Switzerland
| | - G Saposnik
- and Stroke Outcomes and Decision Neuroscience Research Unit (G.S.), Department of Medicine.,Li Ka Shing Knowledge Institute (G.S.), St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - N Kashani
- and Departments of Radiology (M.A., N.K., A.D., M.D.H., M.G., B.K.M.) and
| | - A Demchuk
- From the Department of Clinical Neurosciences (M.A., J.M.O., A.D., M.D.H., M.G., B.K.M.), Hotchkiss Brain Institute.,and Departments of Radiology (M.A., N.K., A.D., M.D.H., M.G., B.K.M.) and
| | - M D Hill
- From the Department of Clinical Neurosciences (M.A., J.M.O., A.D., M.D.H., M.G., B.K.M.), Hotchkiss Brain Institute.,and Departments of Radiology (M.A., N.K., A.D., M.D.H., M.G., B.K.M.) and.,Community Health Sciences (M.A., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Department of Clinical Neurosciences (M.A., J.M.O., A.D., M.D.H., M.G., B.K.M.), Hotchkiss Brain Institute.,and Departments of Radiology (M.A., N.K., A.D., M.D.H., M.G., B.K.M.) and
| | - B K Menon
- From the Department of Clinical Neurosciences (M.A., J.M.O., A.D., M.D.H., M.G., B.K.M.), Hotchkiss Brain Institute .,and Departments of Radiology (M.A., N.K., A.D., M.D.H., M.G., B.K.M.) and.,Community Health Sciences (M.A., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
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11
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Almekhlafi MA, Kunz WG, McTaggart RA, Jayaraman MV, Najm M, Ahn SH, Fainardi E, Rubiera M, Khaw AV, Zini A, Hill MD, Demchuk AM, Goyal M, Menon BK. Imaging Triage of Patients with Late-Window (6-24 Hours) Acute Ischemic Stroke: A Comparative Study Using Multiphase CT Angiography versus CT Perfusion. AJNR Am J Neuroradiol 2019; 41:129-133. [PMID: 31806593 DOI: 10.3174/ajnr.a6327] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The role of collateral imaging in selecting patients for endovascular thrombectomy beyond 6 hours from onset has not been established. To assess the comparative utility of collateral imaging using multiphase CTA in selecting late window patients for EVT. MATERIALS AND METHODS We used data from a prospective multicenter observational study in which all patients underwent imaging with multiphase CT angiography as well as CTP. Two blinded reviewers evaluated patients' eligibility for endovascular thrombectomy using published collateral imaging (multiphase CTA) criteria compared with CTP using the selection criteria of the Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention with Trevo (DAWN) and Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE-3) trials. CTP images were processed using automated commercial software. The outcomes of patients eligible for endovascular thrombectomy according to multiphase CTA, DAWN, or DEFUSE-3 criteria were compared using multivariable logistic regression modeling. Model characteristics were compared using the C-statistic for the receiver operating characteristic curve, the Akaike information criterion, and the Bayesian information criterion. RESULTS Eighty-six patients presented beyond 6 hours from onset/last known well (median, 9.6 hours; interquartile range, 4.1 hours). Thirty-five patients (40.7%) received endovascular thrombectomy, of whom good functional outcome (90-day mRS, 0-2) was achieved in 16/35 (47%). Collateral-based imaging paradigms significantly modified the treatment effect of endovascular thrombectomy on 90-day mRS 0-2 (P interaction = .007). The multiphase CTA-based regression model best fit the data for the 90-day outcome (C-statistic, 0.86; 95% CI, 0.77-0.94) and was associated with the least information loss (Akaike information criterion, 95.7; Bayesian information criterion, 114.9) compared with CTP-based models. CONCLUSIONS The collateral-based imaging paradigm using multiphase CTA compares well with CTP in selecting patients for endovascular thrombectomy in the late time window.
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Affiliation(s)
- M A Almekhlafi
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.)
| | - W G Kunz
- Department of Radiology (W.G.K.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - R A McTaggart
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - M V Jayaraman
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - M Najm
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.)
| | - S H Ahn
- Department of Neurology (S.H.A.), Chosun University School of Medicine, Gwang Ju, South Korea
| | - E Fainardi
- Department of Neurosciences and Rehabilitation (E.F.), University Hospital, Ferrara, Italy
| | - M Rubiera
- Department of Neurology (M.R.), Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, Barcelona, Spain
| | - A V Khaw
- Department of Clinical Neurosciences (A.V.K.), University of Western Ontario, London, Ontario, Canada
| | - A Zini
- Department of Neurology and Stroke Center (A.Z.), Istituto Di Ricovero e Cura a Carattere Scientifico Istituto di Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - M D Hill
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.).,Department of Medicine (M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.)
| | - M Goyal
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.)
| | - B K Menon
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.) .,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.)
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12
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Yogendrakumar V, Al-Ajlan F, Najm M, Puig J, Calleja A, Sohn SI, Ahn SH, Mikulik R, Asdaghi N, Field TS, Jin A, Asil T, Boulanger JM, Hill MD, Demchuk AM, Menon BK, Dowlatshahi D. Clot Burden Score and Early Ischemia Predict Intracranial Hemorrhage following Endovascular Therapy. AJNR Am J Neuroradiol 2019; 40:655-660. [PMID: 30872416 DOI: 10.3174/ajnr.a6009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/11/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage is a known complication following endovascular thrombectomy. The radiologic characteristics of a CT scan may assist with hemorrhage risk stratification. We assessed the radiologic predictors of intracranial hemorrhage following endovascular therapy using data from the INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) study. MATERIALS AND METHODS Patients undergoing endovascular therapy underwent baseline imaging, postprocedural angiography, and 24-hour follow-up imaging. The primary outcome was any intracranial hemorrhage observed on follow-up imaging. The secondary outcome was symptomatic hemorrhage. We assessed the relationship between hemorrhage occurrence and baseline patient characteristics, clinical course, and imaging factors: baseline ASPECTS, thrombus location, residual flow grade, collateralization, and clot burden score. Multivariable logistic regression with backward selection was used to adjust for relevant covariates. RESULTS Of the 199 enrolled patients who met the inclusion criteria, 46 (23%) had an intracranial hemorrhage at 24 hours. On multivariable analysis, postprocedural hemorrhage was associated with pretreatment ASPECTS (OR, 1.56 per point lost; 95% CI, 1.12-2.15), clot burden score (OR, 1.19 per point lost; 95% CI, 1.03-1.38), and ICA thrombus location (OR, 3.10; 95% CI, 1.07-8.91). In post hoc analysis, clot burden scores of ≤3 (sensitivity, 41%; specificity, 82%; OR, 3.12; 95% CI, 1.36-7.15) and pretreatment ASPECTS ≤ 7 (sensitivity, 48%; specificity, 82%; OR, 3.17; 95% CI, 1.35-7.45) robustly predicted hemorrhage. Residual flow grade and collateralization were not associated with hemorrhage occurrence. Symptomatic hemorrhage was observed in 4 patients. CONCLUSIONS Radiologic factors, early ischemia on CT, and increased CTA clot burden are associated with an increased risk of intracranial hemorrhage in patients undergoing endovascular therapy.
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Affiliation(s)
- V Yogendrakumar
- From the Department of Medicine (Neurology) (V.Y., D.D.), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada
| | - F Al-Ajlan
- Department of Neurosciences (F.A.-A.), King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - M Najm
- Calgary Stroke Program (M.N., M.D.H., A.M.D., B.K.M.), Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - J Puig
- Institut de Diagnostic per la Imatge (J.P.), Girona Biomedical Research Institute, University Hospital Dr Josep Trueta, Girona, Spain
| | - A Calleja
- Department of Neurology (A.C.), Stroke Unit, Hospital Clínico Universitario de Valladolid, Universidad de Valladolid, Valladolid, Spain
| | - S-I Sohn
- Department of Neurology (S-.I.S.), Keimyung University, Daegu, Republic of Korea
| | - S H Ahn
- Department of Neurology (S.H.A.), Chosun University School of Medicine and Hospital, Gwangju, Republic of Korea
| | - R Mikulik
- International Clinical Research Center (R.M.), St. Anne's University Hospital, Brno, Czech Republic
| | - N Asdaghi
- Department of Neurology (N.A.), Miller School of Medicine, University of Miami, Miami, Florida
| | - T S Field
- Division of Neurology (T.S.F.), Vancouver Stroke Program, University of British Columbia, Vancouver, Canada
| | - A Jin
- Division of Neurology (A.J.), Queen's University, Kingston, Canada
| | - T Asil
- Bezmialem Vakif Üniversitesi Nöroloji (T.A., J.-M.B.), Istanbul, Turkey
| | - J-M Boulanger
- Bezmialem Vakif Üniversitesi Nöroloji (T.A., J.-M.B.), Istanbul, Turkey
- Department of Medicine (J.-M.B.), Charles LeMoyne Hospital, Greenfield Park, Canada
| | - M D Hill
- Calgary Stroke Program (M.N., M.D.H., A.M.D., B.K.M.), Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - A M Demchuk
- Calgary Stroke Program (M.N., M.D.H., A.M.D., B.K.M.), Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - B K Menon
- Calgary Stroke Program (M.N., M.D.H., A.M.D., B.K.M.), Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - D Dowlatshahi
- From the Department of Medicine (Neurology) (V.Y., D.D.), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada
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13
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Almekhlafi MA, Kunz WG, Menon BK, McTaggart RA, Jayaraman MV, Baxter BW, Heck D, Frei D, Derdeyn CP, Takagi T, Aamodt AH, Fragata IMR, Hill MD, Demchuk AM, Goyal M. Imaging of Patients with Suspected Large-Vessel Occlusion at Primary Stroke Centers: Available Modalities and a Suggested Approach. AJNR Am J Neuroradiol 2019; 40:396-400. [PMID: 30705072 DOI: 10.3174/ajnr.a5971] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/06/2018] [Indexed: 12/24/2022]
Abstract
The overwhelming benefit of endovascular therapy in patients with large-vessel occlusions suggests that more patients will be screened than treated. Some of those patients will be evaluated first at primary stroke centers; this type of evaluation calls for standardizing the imaging approach to minimize delays in assessing, transferring, and treating these patients. Here, we propose that CT angiography (performed at the same time as head CT) should be the minimum imaging approach for all patients with stroke with suspected large-vessel occlusion presenting to primary stroke centers. We discuss some of the implications of this approach and how to facilitate them.
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Affiliation(s)
- M A Almekhlafi
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - W G Kunz
- Department of Radiology (W.G.K.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - B K Menon
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - R A McTaggart
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - M V Jayaraman
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - B W Baxter
- Department of Radiology (B.W.B.), Erlanger Medical Center, Chattanooga, Tennessee
| | - D Heck
- Department of Radiology (D.H.), Forsyth Medical Center, Winston Salem, North Carolina
| | - D Frei
- Swedish Medical Center (D.F.), Denver, Colorado
| | - C P Derdeyn
- Department of Radiology (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - T Takagi
- Department of Neurosurgery (T.T.), Hyogo College of Medicine, Nishinomiya, Hyögo, Japan
| | - A H Aamodt
- Department of Neurology (A.H.A.), Oslo University Hospital, Oslo, Norway
| | - I M R Fragata
- Department of Neuroradiology (I.M.R.F.), Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - M D Hill
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Departments of Radiology and Clinical Neurosciences (M.A.A., B.K.M., M.D.H., A.M.D., M.G.), University of Calgary, Calgary, Alberta, Canada
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14
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Kuang H, Najm M, Chakraborty D, Maraj N, Sohn SI, Goyal M, Hill MD, Demchuk AM, Menon BK, Qiu W. Automated ASPECTS on Noncontrast CT Scans in Patients with Acute Ischemic Stroke Using Machine Learning. AJNR Am J Neuroradiol 2019; 40:33-38. [PMID: 30498017 DOI: 10.3174/ajnr.a5889] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/08/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Alberta Stroke Program Early CT Score (ASPECTS) was devised as a systematic method to assess the extent of early ischemic change on noncontrast CT (NCCT) in patients with acute ischemic stroke (AIS). Our aim was to automate ASPECTS to objectively score NCCT of AIS patients. MATERIALS AND METHODS We collected NCCT images with a 5-mm thickness of 257 patients with acute ischemic stroke (<8 hours from onset to scans) followed by a diffusion-weighted imaging acquisition within 1 hour. Expert ASPECTS readings on DWI were used as ground truth. Texture features were extracted from each ASPECTS region of the 157 training patient images to train a random forest classifier. The unseen 100 testing patient images were used to evaluate the performance of the trained classifier. Statistical analyses on the total ASPECTS and region-level ASPECTS were conducted. RESULTS For the total ASPECTS of the unseen 100 patients, the intraclass correlation coefficient between the automated ASPECTS method and DWI ASPECTS scores of expert readings was 0.76 (95% confidence interval, 0.67-0.83) and the mean ASPECTS difference in the Bland-Altman plot was 0.3 (limits of agreement, -3.3, 2.6). Individual ASPECTS region-level analysis showed that our method yielded κ = 0.60, sensitivity of 66.2%, specificity of 91.8%, and area under curve of 0.79 for 100 × 10 ASPECTS regions. Additionally, when ASPECTS was dichotomized (>4 and ≤4), κ = 0.78, sensitivity of 97.8%, specificity of 80%, and area under the curve of 0.89 were generated between the proposed method and expert readings on DWI. CONCLUSIONS The proposed automated ASPECTS scoring approach shows reasonable ability to determine ASPECTS on NCCT images in patients presenting with acute ischemic stroke.
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Affiliation(s)
- H Kuang
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - M Najm
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - D Chakraborty
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - N Maraj
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - S I Sohn
- Department of Neurology (S.I.S.), Keimyung University, Daegu, South Korea
| | - M Goyal
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
- Department of Clinical Neurosciences, Department of Radiology (M.D.H., A.M.D., M.G., B.K.M.)
- Hotchkiss Brain Institute, Calgary, Alberta, Canada (M.D.H., A.M.D., M.G., B.K.M.)
| | - M D Hill
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
- Department of Clinical Neurosciences, Department of Radiology (M.D.H., A.M.D., M.G., B.K.M.)
- Department of Community Health Sciences (M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada (M.D.H., A.M.D., M.G., B.K.M.)
| | - A M Demchuk
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
- Department of Clinical Neurosciences, Department of Radiology (M.D.H., A.M.D., M.G., B.K.M.)
- Hotchkiss Brain Institute, Calgary, Alberta, Canada (M.D.H., A.M.D., M.G., B.K.M.)
| | - B K Menon
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
- Department of Clinical Neurosciences, Department of Radiology (M.D.H., A.M.D., M.G., B.K.M.)
- Department of Community Health Sciences (M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada (M.D.H., A.M.D., M.G., B.K.M.)
| | - W Qiu
- From the Calgary Stroke Program (H.K., W.Q., M.N., D.C., N.M., M.G., M.D.H., A.M.D., B.K.M.)
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15
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Qiu W, Kuang H, Nair J, Assis Z, Najm M, McDougall C, McDougall B, Chung K, Wilson AT, Goyal M, Hill MD, Demchuk AM, Menon BK. Radiomics-Based Intracranial Thrombus Features on CT and CTA Predict Recanalization with Intravenous Alteplase in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2018; 40:39-44. [PMID: 30573458 DOI: 10.3174/ajnr.a5918] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/21/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Thrombus characteristics identified on non-contrast CT (NCCT) are potentially associated with recanalization with intravenous (IV) alteplase in patients with acute ischemic stroke (AIS). Our aim was to determine the best radiomics-based features of thrombus on NCCT and CT angiography associated with recanalization with IV alteplase in AIS patients and proximal intracranial thrombi. MATERIALS AND METHODS With a nested case-control design, 67 patients with ICA/M1 MCA segment thrombus treated with IV alteplase were included in this analysis. Three hundred twenty-six radiomics features were extracted from each thrombus on both NCCT and CTA images. Linear discriminative analysis was applied to select features most strongly associated with early recanalization with IV alteplase. These features were then used to train a linear support vector machine classifier. Ten times 5-fold cross-validation was used to evaluate the accuracy of the trained classifier and the stability of the selected features. RESULTS Receiver operating characteristic curves showed that thrombus radiomics features are predictive of early recanalization with IV alteplase. The combination of radiomics features from NCCT, CTA, and radiomics changes is best associated with early recanalization with IV alteplase (area under the curve = 0.85) and was significantly better than any single feature such as thrombus length (P < .001), volume (P < .001), and permeability as measured by mean attenuation increase (P < .001), maximum attenuation in CTA (P < .001), maximum attenuation increase (P < .001), and assessment of residual flow grade (P < .001). CONCLUSIONS Thrombus radiomics features derived from NCCT and CTA are more predictive of recanalization with IV alteplase in patients with acute ischemic stroke with proximal occlusion than previously known thrombus imaging features such as length, volume, and permeability.
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Affiliation(s)
- W Qiu
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - H Kuang
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - J Nair
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.).,Department of Radiology (J.N.), McMaster University, Hamilton, Ontario, Canada
| | - Z Assis
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - M Najm
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - C McDougall
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - B McDougall
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - K Chung
- Calgary Stroke Program, Mechanical and Manufacturing Engineering (K.C.)
| | - A T Wilson
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.)
| | - M Goyal
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.).,Radiology (M.D.H., A.M.D., M.G., B.K.M.).,Hotchkiss Brain Institute (M.D.H., A.M.D., M.G., B.K.M.), Calgary, Alberta, Canada
| | - M D Hill
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.).,Radiology (M.D.H., A.M.D., M.G., B.K.M.).,Community Health Sciences (M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute (M.D.H., A.M.D., M.G., B.K.M.), Calgary, Alberta, Canada
| | - A M Demchuk
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.).,Radiology (M.D.H., A.M.D., M.G., B.K.M.).,Hotchkiss Brain Institute (M.D.H., A.M.D., M.G., B.K.M.), Calgary, Alberta, Canada
| | - B K Menon
- From the Departments of Clinical Neurosciences (W.Q., H.K., J.N., Z.A. M.N., C.M., A.T.W., B.M., M.G., M.D.H., A.M.D., B.K.M.) .,Radiology (M.D.H., A.M.D., M.G., B.K.M.).,Community Health Sciences (M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute (M.D.H., A.M.D., M.G., B.K.M.), Calgary, Alberta, Canada
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Román LS, Menon BK, Blasco J, Hernández-Pérez M, Dávalos A, Majoie CBLM, Campbell BCV, Guillemin F, Lingsma H, Anxionnat R, Epstein J, Saver JL, Marquering H, Wong JH, Lopes D, Reimann G, Desal H, Dippel DWJ, Coutts S, du Mesnil de Rochemont R, Yavagal D, Ferre JC, Roos YBWEM, Liebeskind DS, Lenthall R, Molina C, Al Ajlan FS, Reddy V, Dowlatshahi D, Sourour NA, Oppenheim C, Mitha AP, Davis SM, Weimar C, van Oostenbrugge RJ, Cobo E, Kleinig TJ, Donnan GA, van der Lugt A, Demchuk AM, Berkhemer OA, Boers AMM, Ford GA, Muir KW, Brown BS, Jovin T, van Zwam WH, Mitchell PJ, Hill MD, White P, Bracard S, Goyal M, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle J, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach Z, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S, Wakhloo A, Moonis M, Henniger N, Goddeau R, van den Berg R, Massari F, Minaeian A, Lozano JD, Ramzan M, Stout C, Patel A, Tunguturi A, Onteddu S, Carandang R, Howk M, Koudstaal PJ, Ribó M, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Meler P, Huerga E, Gelabert S, Coscojuela P, van Zwam WH, Tomasello A, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Rovira A, Molina CA, Millán M, Muñoz L, Roos YB, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, García Bermejo P, Remollo S, Castaño C, García-Sort R, van der Lugt A, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Dávalos A, Chamorro A, Urra X, Obach V, van Oostenbrugge RJ, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Ariño H, Aceituno A, Rudilosso S, Renu A, Majoie CB, Macho JM, San Roman L, Blasco J, López A, Macías N, Cardona P, Quesada H, Rubio F, Cano L, Lara B, Dippel DW, de Miquel MA, Aja L, Serena J, Cobo E, Albers GW, Lees KR, Arenillas J, Roberts R, Minhas P, Al-Ajlan F, Brown MM, Salluzzi M, Zimmel L, Patel S, Eesa M, Martí-Fàbregas J, Jankowitz B, Serena J, Salvat-Plana M, López-Cancio E, Bracard S, Liebig T, Ducrocq X, Anxionnat R, Baillot PA, Barbier C, Derelle AL, Lacour JC, Richard S, Samson Y, Sourour N, Baronnet-Chauvet F, Stijnen T, Clarencon F, Crozier S, Deltour S, Di Maria F, Le Bouc R, Leger A, Mutlu G, Rosso C, Szatmary Z, Yger M, Andersson T, Zavanone C, Bakchine S, Pierot L, Caucheteux N, Estrade L, Kadziolka K, Leautaud A, Renkes C, Serre I, Desal H, Mattle H, Guillon B, Boutoleau-Bretonniere C, Daumas-Duport B, De Gaalon S, Derkinderen P, Evain S, Herisson F, Laplaud DA, Lebouvier T, Lintia-Gaultier A, Wahlgren N, Pouclet-Courtemanche H, Rouaud T, Rouaud Jaffrenou V, Schunck A, Sevin-Allouet M, Toulgoat F, Wiertlewski S, Gauvrit JY, Ronziere T, Cahagne V, van der Heijden E, Ferre JC, Pinel JF, Raoult H, Mas JL, Meder JF, Al Najjar-Carpentier AA, Birchenall J, Bodiguel E, Calvet D, Domigo V, Ghannouti N, Godon-Hardy S, Guiraud V, Lamy C, Majhadi L, Morin L, Naggara O, Trystram D, Turc G, Berge J, Sibon I, Fleitour N, Menegon P, Barreau X, Rouanet F, Debruxelles S, Kazadi A, Renou P, Fleury O, Pasco-Papon A, Dubas F, Caroff J, Hooijenga I, Godard Ducceschi S, Hamon MA, Lecluse A, Marc G, Giroud M, Ricolfi F, Bejot Y, Chavent A, Gentil A, Kazemi A, Puppels C, Osseby GV, Voguet C, Mahagne MH, Sedat J, Chau Y, Suissa L, Lachaud S, Houdart E, Stapf C, Buffon Porcher F, Pellikaan W, Chabriat H, Guedin P, Herve D, Jouvent E, Mawet J, Saint-Maurice JP, Schneble HM, Turjman F, Nighoghossian N, Berhoune NN, Geerling A, Bouhour F, Cho TH, Derex L, Felix S, Gervais-Bernard H, Gory B, Manera L, Mechtouff L, Ritzenthaler T, Riva R, Lindl-Velema A, Salaris Silvio F, Tilikete C, Blanc R, Obadia M, Bartolini MB, Gueguen A, Piotin M, Pistocchi S, Redjem H, Drouineau J, van Vemde G, Neau JP, Godeneche G, Lamy M, Marsac E, Velasco S, Clavelou P, Chabert E, Bourgois N, Cornut-Chauvinc C, Ferrier A, de Ridder A, Gabrillargues J, Jean B, Marques AR, Vitello N, Detante O, Barbieux M, Boubagra K, Favre Wiki I, Garambois K, Tahon F, Greebe P, Ashok V, Voguet C, Coskun O, Guedin P, Rodesch G, Lapergue B, Bourdain F, Evrard S, Graveleau P, Decroix JP, de Bont-Stikkelbroeck J, Wang A, Sellal F, Ahle G, Carelli G, Dugay MH, Gaultier C, Lebedinsky AP, Lita L, Musacchio RM, Renglewicz-Destuynder C, de Meris J, Tournade A, Vuillemet F, Montoro FM, Mounayer C, Faugeras F, Gimenez L, Labach C, Lautrette G, Denier C, Saliou G, Janssen K, Chassin O, Dussaule C, Melki E, Ozanne A, Puccinelli F, Sachet M, Sarov M, Bonneville JF, Moulin T, Biondi A, Struijk W, De Bustos Medeiros E, Vuillier F, Courtheoux P, Viader F, Apoil-Brissard M, Bataille M, Bonnet AL, Cogez J, Kazemi A, Touze E, Licher S, Leclerc X, Leys D, Aggour M, Aguettaz P, Bodenant M, Cordonnier C, Deplanque D, Girot M, Henon H, Kalsoum E, Boodt N, Lucas C, Pruvo JP, Zuniga P, Bonafé A, Arquizan C, Costalat V, Machi P, Mourand I, Riquelme C, Bounolleau P, Ros A, Arteaga C, Faivre A, Bintner M, Tournebize P, Charlin C, Darcel F, Gauthier-Lasalarie P, Jeremenko M, Mouton S, Zerlauth JB, Venema E, Lamy C, Hervé D, Hassan H, Gaston A, Barral FG, Garnier P, Beaujeux R, Wolff V, Herbreteau D, Debiais S, Slokkers I, Murray A, Ford G, Muir KW, White P, Brown MM, Clifton A, Freeman J, Ford I, Markus H, Wardlaw J, Ganpat RJ, Lees KR, Molyneux A, Robinson T, Lewis S, Norrie J, Robertson F, Perry R, Dixit A, Cloud G, Clifton A, Mulder M, Madigan J, Roffe C, Nayak S, Lobotesis K, Smith C, Herwadkar A, Kandasamy N, Goddard T, Bamford J, Subramanian G, Saiedie N, Lenthall R, Littleton E, Lamin S, Storey K, Ghatala R, Banaras A, Aeron-Thomas J, Hazel B, Maguire H, Veraque E, Heshmatollah A, Harrison L, Keshvara R, Cunningham J, Schipperen S, Vinken S, van Boxtel T, Koets J, Boers M, Santos E, Borst J, Jansen I, Kappelhof M, Lucas M, Geuskens R, Barros RS, Dobbe R, Csizmadia M, Hill MD, Goyal M, Demchuk AM, Menon BK, Eesa M, Ryckborst KJ, Wright MR, Kamal NR, Andersen L, Randhawa PA, Stewart T, Patil S, Minhas P, Almekhlafi M, Mishra S, Clement F, Sajobi T, Shuaib A, Montanera WJ, Roy D, Silver FL, Jovin TG, Frei DF, Sapkota B, Rempel JL, Thornton J, Williams D, Tampieri D, Poppe AY, Dowlatshahi D, Wong JH, Mitha AP, Subramaniam S, Hull G, Lowerison MW, Sajobi T, Salluzzi M, Wright MR, Maxwell M, Lacusta S, Drupals E, Armitage K, Barber PA, Smith EE, Morrish WF, Coutts SB, Derdeyn C, Demaerschalk B, Yavagal D, Martin R, Brant R, Yu Y, Willinsky RA, Montanera WJ, Weill A, Kenney C, Aram H, Stewart T, Stys PK, Watson TW, Klein G, Pearson D, Couillard P, Trivedi A, Singh D, Klourfeld E, Imoukhuede O, Nikneshan D, Blayney S, Reddy R, Choi P, Horton M, Musuka T, Dubuc V, Field TS, Desai J, Adatia S, Alseraya A, Nambiar V, van Dijk R, Wong JH, Mitha AP, Morrish WF, Eesa M, Newcommon NJ, Shuaib A, Schwindt B, Butcher KS, Jeerakathil T, Buck B, Khan K, Naik SS, Emery DJ, Owen RJ, Kotylak TB, Ashforth RA, Yeo TA, McNally D, Siddiqui M, Saqqur M, Hussain D, Kalashyan H, Manosalva A, Kate M, Gioia L, Hasan S, Mohammad A, Muratoglu M, Williams D, Thornton J, Cullen A, Brennan P, O'Hare A, Looby S, Hyland D, Duff S, McCusker M, Hallinan B, Lee S, McCormack J, Moore A, O'Connor M, Donegan C, Brewer L, Martin A, Murphy S, O'Rourke K, Smyth S, Kelly P, Lynch T, Daly T, O'Brien P, O'Driscoll A, Martin M, Daly T, Collins R, Coughlan T, McCabe D, Murphy S, O'Neill D, Mulroy M, Lynch O, Walsh T, O'Donnell M, Galvin T, Harbison J, McElwaine P, Mulpeter K, McLoughlin C, Reardon M, Harkin E, Dolan E, Watts M, Cunningham N, Fallon C, Gallagher S, Cotter P, Crowe M, Doyle R, Noone I, Lapierre M, Coté VA, Lanthier S, Odier C, Durocher A, Raymond J, Weill A, Daneault N, Deschaintre Y, Jankowitz B, Baxendell L, Massaro L, Jackson-Graves C, Decesare S, Porter P, Armbruster K, Adams A, Billigan J, Oakley J, Ducruet A, Jadhav A, Giurgiutiu DV, Aghaebrahim A, Reddy V, Hammer M, Starr M, Totoraitis V, Wechsler L, Streib S, Rangaraju S, Campbell D, Rocha M, Gulati D, Silver FL, Krings T, Kalman L, Cayley A, Williams J, Stewart T, Wiegner R, Casaubon LK, Jaigobin C, del Campo JM, Elamin E, Schaafsma JD, Willinsky RA, Agid R, Farb R, ter Brugge K, Sapkoda BL, Baxter BW, Barton K, Knox A, Porter A, Sirelkhatim A, Devlin T, Dellinger C, Pitiyanuvath N, Patterson J, Nichols J, Quarfordt S, Calvert J, Hawk H, Fanale C, Frei DF, Bitner A, Novak A, Huddle D, Bellon R, Loy D, Wagner J, Chang I, Lampe E, Spencer B, Pratt R, Bartt R, Shine S, Dooley G, Nguyen T, Whaley M, McCarthy K, Teitelbaum J, Tampieri D, Poon W, Campbell N, Cortes M, Dowlatshahi D, Lum C, Shamloul R, Robert S, Stotts G, Shamy M, Steffenhagen N, Blacquiere D, Hogan M, AlHazzaa M, Basir G, Lesiuk H, Iancu D, Santos M, Choe H, Weisman DC, Jonczak K, Blue-Schaller A, Shah Q, MacKenzie L, Klein B, Kulandaivel K, Kozak O, Gzesh DJ, Harris LJ, Khoury JS, Mandzia J, Pelz D, Crann S, Fleming L, Hesser K, Beauchamp B, Amato-Marzialli B, Boulton M, Lopez-Ojeda P, Sharma M, Lownie S, Chan R, Swartz R, Howard P, Golob D, Gladstone D, Boyle K, Boulos M, Hopyan J, Yang V, Da Costa L, Holmstedt CA, Turk AS, Navarro R, Jauch E, Ozark S, Turner R, Phillips S, Shankar J, Jarrett J, Gubitz G, Maloney W, Vandorpe R, Schmidt M, Heidenreich J, Hunter G, Kelly M, Whelan R, Peeling L, Burns PA, Hunter A, Wiggam I, Kerr E, Watt M, Fulton A, Gordon P, Rennie I, Flynn P, Smyth G, O'Leary S, Gentile N, Linares G, McNelis P, Erkmen K, Katz P, Azizi A, Weaver M, Jungreis C, Faro S, Shah P, Reimer H, Kalugdan V, Saposnik G, Bharatha A, Li Y, Kostyrko P, Santos M, Marotta T, Montanera W, Sarma D, Selchen D, Spears J, Heo JH, Jeong K, Kim DJ, Kim BM, Kim YD, Song D, Lee KJ, Yoo J, Bang OY, Rho S, Lee J, Jeon P, Kim KH, Cha J, Kim SJ, Ryoo S, Lee MJ, Sohn SI, Kim CH, Ryu HG, Hong JH, Chang HW, Lee CY, Rha J, Davis SM, Donnan GA, Campbell BCV, Mitchell PJ, Churilov L, Yan B, Dowling R, Yassi N, Oxley TJ, Wu TY, Silver G, McDonald A, McCoy R, Kleinig TJ, Scroop R, Dewey HM, Simpson M, Brooks M, Coulton B, Krause M, Harrington TJ, Steinfort B, Faulder K, Priglinger M, Day S, Phan T, Chong W, Holt M, Chandra RV, Ma H, Young D, Wong K, Wijeratne T, Tu H, Mackay E, Celestino S, Bladin CF, Loh PS, Gilligan A, Ross Z, Coote S, Frost T, Parsons MW, Miteff F, Levi CR, Ang T, Spratt N, Kaauwai L, Badve M, Rice H, de Villiers L, Barber PA, McGuinness B, Hope A, Moriarty M, Bennett P, Wong A, Coulthard A, Lee A, Jannes J, Field D, Sharma G, Salinas S, Cowley E, Snow B, Kolbe J, Stark R, King J, Macdonnell R, Attia J, D'Este C, Saver JL, Goyal M, Diener HC, Levy EI, Bonafé A, Mendes Pereira V, Jahan R, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, von Kummer R, Smith W, Turjman F, Hamilton S, Chiacchierini R, Amar A, Sanossian N, Loh Y, Devlin T, Baxter B, Hawk H, Sapkota B, Quarfordt S, Sirelkhatim A, Dellinger C, Barton K, Reddy VK, Ducruet A, Jadhav A, Horev A, Giurgiutiu DV, Totoraitis V, Hammer M, Jankowitz B, Wechsler L, Rocha M, Gulati D, Campbell D, Star M, Baxendell L, Oakley J, Siddiqui A, Hopkins LN, Snyder K, Sawyer R, Hall S, Costalat V, Riquelme C, Machi P, Omer E, Arquizan C, Mourand I, Charif M, Ayrignac X, Menjot de Champfleur N, Leboucq N, Gascou G, Moynier M, du Mesnil de Rochemont R, Singer O, Berkefeld J, Foerch C, Lorenz M, Pfeilschifer W, Hattingen E, Wagner M, You SJ, Lescher S, Braun H, Dehkharghani S, Belagaje SR, Anderson A, Lima A, Obideen M, Haussen D, Dharia R, Frankel M, Patel V, Owada K, Saad A, Amerson L, Horn C, Doppelheuer S, Schindler K, Lopes DK, Chen M, Moftakhar R, Anton C, Smreczak M, Carpenter JS, Boo S, Rai A, Roberts T, Tarabishy A, Gutmann L, Brooks C, Brick J, Domico J, Reimann G, Hinrichs K, Becker M, Heiss E, Selle C, Witteler A, Al-Boutros S, Danch MJ, Ranft A, Rohde S, Burg K, Weimar C, Zegarac V, Hartmann C, Schlamann M, Göricke S, Ringlestein A, Wanke I, Mönninghoff C, Dietzold M, Budzik R, Davis T, Eubank G, Hicks WJ, Pema P, Vora N, Mejilla J, Taylor M, Clark W, Rontal A, Fields J, Peterson B, Nesbit G, Lutsep H, Bozorgchami H, Priest R, Ologuntoye O, Barnwell S, Dogan A, Herrick K, Takahasi C, Beadell N, Brown B, Jamieson S, Hussain MS, Russman A, Hui F, Wisco D, Uchino K, Khawaja Z, Katzan I, Toth G, Cheng-Ching E, Bain M, Man S, Farrag A, George P, John S, Shankar L, Drofa A, Dahlgren R, Bauer A, Itreat A, Taqui A, Cerejo R, Richmond A, Ringleb P, Bendszus M, Möhlenbruch M, Reiff T, Amiri H, Purrucker J, Herweh C, Pham M, Menn O, Ludwig I, Acosta I, Villar C, Morgan W, Sombutmai C, Hellinger F, Allen E, Bellew M, Gandhi R, Bonwit E, Aly J, Ecker RD, Seder D, Morris J, Skaletsky M, Belden J, Baker C, Connolly LS, Papanagiotou P, Roth C, Kastrup A, Politi M, Brunner F, Alexandrou M, Merdivan H, Ramsey C, Given II C, Renfrow S, Deshmukh V, Sasadeusz K, Vincent F, Thiesing JT, Putnam J, Bhatt A, Kansara A, Caceves D, Lowenkopf T, Yanase L, Zurasky J, Dancer S, Freeman B, Scheibe-Mirek T, Robison J, Rontal A, Roll J, Clark D, Rodriguez M, Fitzsimmons BFM, Zaidat O, Lynch JR, Lazzaro M, Larson T, Padmore L, Das E, Farrow-Schmidt A, Hassan A, Tekle W, Cate C, Jansen O, Cnyrim C, Wodarg F, Wiese C, Binder A, Riedel C, Rohr A, Lang N, Laufs H, Krieter S, Remonda L, Diepers M, Añon J, Nedeltchev K, Kahles T, Biethahn S, Lindner M, Chang V, Gächter C, Esperon C, Guglielmetti M, Arenillas Lara JF, Martínez Galdámez M, Calleja Sanz AI, Cortijo Garcia E, Garcia Bermejo P, Perez S, Mulero Carrillo P, Crespo Vallejo E, Ruiz Piñero M, Lopez Mesonero L, Reyes Muñoz FJ, Brekenfeld C, Buhk JH, Krützelmann A, Thomalla G, Cheng B, Beck C, Hoppe J, Goebell E, Holst B, Grzyska U, Wortmann G, Starkman S, Duckwiler G, Jahan R, Rao N, Sheth S, Ng K, Noorian A, Szeder V, Nour M, McManus M, Huang J, Tarpley J, Tateshima S, Gonzalez N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D. Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 2018; 17:895-904. [DOI: 10.1016/s1474-4422(18)30242-4] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022]
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Campbell BCV, van Zwam WH, Goyal M, Menon BK, Dippel DWJ, Demchuk AM, Bracard S, White P, Dávalos A, Majoie CBLM, van der Lugt A, Ford GA, de la Ossa NP, Kelly M, Bourcier R, Donnan GA, Roos YBWEM, Bang OY, Nogueira RG, Devlin TG, van den Berg LA, Clarençon F, Burns P, Carpenter J, Berkhemer OA, Yavagal DR, Pereira VM, Ducrocq X, Dixit A, Quesada H, Epstein J, Davis SM, Jansen O, Rubiera M, Urra X, Micard E, Lingsma HF, Naggara O, Brown S, Guillemin F, Muir KW, van Oostenbrugge RJ, Saver JL, Jovin TG, Hill MD, Mitchell PJ, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle J, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer 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Chang HW, Lee CY, Rha J, Davis SM, Donnan GA, Campbell BCV, Mitchell PJ, Churilov L, Yan B, Dowling R, Yassi N, Oxley TJ, Wu TY, Silver G, McDonald A, McCoy R, Kleinig TJ, Scroop R, Dewey HM, Simpson M, Brooks M, Coulton B, Krause M, Harrington TJ, Steinfort B, Faulder K, Priglinger M, Day S, Phan T, Chong W, Holt M, Chandra RV, Ma H, Young D, Wong K, Wijeratne T, Tu H, Mackay E, Celestino S, Bladin CF, Loh PS, Gilligan A, Ross Z, Coote S, Frost T, Parsons MW, Miteff F, Levi CR, Ang T, Spratt N, Kaauwai L, Badve M, Rice H, de Villiers L, Barber PA, McGuinness B, Hope A, Moriarty M, Bennett P, Wong A, Coulthard A, Lee A, Jannes J, Field D, Sharma G, Salinas S, Cowley E, Snow B, Kolbe J, Stark R, King J, Macdonnell R, Attia J, D'Este C, Saver JL, Goyal M, Diener HC, Levy EI, Bonafé A, Mendes Pereira V, Jahan R, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, von Kummer R, Smith W, Turjman F, Hamilton S, Chiacchierini R, Amar A, Sanossian N, Loh Y, Devlin T, Baxter B, Hawk H, Sapkota B, Quarfordt S, Sirelkhatim A, Dellinger C, Barton K, Reddy VK, Ducruet A, Jadhav A, Horev A, Giurgiutiu DV, Totoraitis V, Hammer M, Jankowitz B, Wechsler L, Rocha M, Gulati D, Campbell D, Star M, Baxendell L, Oakley J, Siddiqui A, Hopkins LN, Snyder K, Sawyer R, Hall S, Costalat V, Riquelme C, Machi P, Omer E, Arquizan C, Mourand I, Charif M, Ayrignac X, Menjot de Champfleur N, Leboucq N, Gascou G, Moynier M, du Mesnil de Rochemont R, Singer O, Berkefeld J, Foerch C, Lorenz M, Pfeilschifer W, Hattingen E, Wagner M, You SJ, Lescher S, Braun H, Dehkharghani S, Belagaje SR, Anderson A, Lima A, Obideen M, Haussen D, Dharia R, Frankel M, Patel V, Owada K, Saad A, Amerson L, Horn C, Doppelheuer S, Schindler K, Lopes DK, Chen M, Moftakhar R, Anton C, Smreczak M, Carpenter JS, Boo S, Rai A, Roberts T, Tarabishy A, Gutmann L, Brooks C, Brick J, Domico J, Reimann G, Hinrichs K, Becker M, Heiss E, Selle C, Witteler A, Al-Boutros S, Danch MJ, Ranft A, Rohde S, Burg K, Weimar C, Zegarac V, Hartmann C, Schlamann M, Göricke S, Ringlestein A, Wanke I, Mönninghoff C, Dietzold M, Budzik R, Davis T, Eubank G, Hicks WJ, Pema P, Vora N, Mejilla J, Taylor M, Clark W, Rontal A, Fields J, Peterson B, Nesbit G, Lutsep H, Bozorgchami H, Priest R, Ologuntoye O, Barnwell S, Dogan A, Herrick K, Takahasi C, Beadell N, Brown B, Jamieson S, Hussain MS, Russman A, Hui F, Wisco D, Uchino K, Khawaja Z, Katzan I, Toth G, Cheng-Ching E, Bain M, Man S, Farrag A, George P, John S, Shankar L, Drofa A, Dahlgren R, Bauer A, Itreat A, Taqui A, Cerejo R, Richmond A, Ringleb P, Bendszus M, Möhlenbruch M, Reiff T, Amiri H, Purrucker J, Herweh C, Pham M, Menn O, Ludwig I, Acosta I, Villar C, Morgan W, Sombutmai C, Hellinger F, Allen E, Bellew M, Gandhi R, Bonwit E, Aly J, Ecker RD, Seder D, Morris J, Skaletsky M, Belden J, Baker C, Connolly LS, Papanagiotou P, Roth C, Kastrup A, Politi M, Brunner F, Alexandrou M, Merdivan H, Ramsey C, Given II C, Renfrow S, Deshmukh V, Sasadeusz K, Vincent F, Thiesing JT, Putnam J, Bhatt A, Kansara A, Caceves D, Lowenkopf T, Yanase L, Zurasky J, Dancer S, Freeman B, Scheibe-Mirek T, Robison J, Rontal A, Roll J, Clark D, Rodriguez M, Fitzsimmons BFM, Zaidat O, Lynch JR, Lazzaro M, Larson T, Padmore L, Das E, Farrow-Schmidt A, Hassan A, Tekle W, Cate C, Jansen O, Cnyrim C, Wodarg F, Wiese C, Binder A, Riedel C, Rohr A, Lang N, Laufs H, Krieter S, Remonda L, Diepers M, Añon J, Nedeltchev K, Kahles T, Biethahn S, Lindner M, Chang V, Gächter C, Esperon C, Guglielmetti M, Arenillas Lara JF, Martínez Galdámez M, Calleja Sanz AI, Cortijo Garcia E, Garcia Bermejo P, Perez S, Mulero Carrillo P, Crespo Vallejo E, Ruiz Piñero M, Lopez Mesonero L, Reyes Muñoz FJ, Brekenfeld C, Buhk JH, Krützelmann A, Thomalla G, Cheng B, Beck C, Hoppe J, Goebell E, Holst B, Grzyska U, Wortmann G, Starkman S, Duckwiler G, Jahan R, Rao N, Sheth S, Ng K, Noorian A, Szeder V, Nour M, McManus M, Huang J, Tarpley J, Tateshima S, Gonzalez N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol 2018; 17:47-53. [DOI: 10.1016/s1474-4422(17)30407-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/05/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
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Motyer R, Kok HK, Asadi H, O'Hare A, Brennan P, Power S, Looby S, Nicholson P, Williams D, Murphy S, Hill MD, Goyal M, McManus J, O'Brien P, Thornton J. Outcomes of endovascular treatment for acute large-vessel ischaemic stroke more than 6 h after symptom onset. J Intern Med 2017; 282:537-545. [PMID: 28875550 DOI: 10.1111/joim.12680] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Benefit from endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) is well demonstrated. Furthermore, emerging evidence supports efficacy in appropriately selected patients treated beyond current recommendations of 6 h. We evaluated clinical outcomes in patients undergoing late EVT at our institution. METHODS Retrospective review of prospectively collected clinical database on 355 patients who underwent EVT for LVO AIS. Data collected consisted of patient demographics, radiological findings and outcome details. Outcomes, including 90-day functional status, recanalization, symptomatic intracranial haemorrhage (sICH) and 90-day mortality, for patients undergoing EVT <6 h, >6 h, and >7.3 h, were compared. RESULTS A total of 355 patients underwent EVT for LVO AIS at our institution during the review period, with 74 (21%) patients treated ≥6 h from symptom onset. Successful recanalization was achieved in 285 (80%) patients, with 228 (81%) achieving a mTICI ≥2b in the <6 h group, and 57 (77%) in the >6 h group (P = 0.429). Ninety-day functional independence (mRS 0-2) was achieved in 162 (46%) patients, with 130 (46%) achieving a mRS of 0-2 in the <6 h group, and 32 (43%) in the >6 h group (P = 0.643). No significant differences were found in rates of sICH or 90-day mortality. No significant differences in functional independence, recanalization rates, sICH or mortality were identified in patients treated with EVT >7.3 h compared to <7.3 h. CONCLUSIONS In appropriately selected patients, EVT >6 h was associated with comparable outcomes to those treated <6 h. These data support a physiological approach to patient selection.
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Affiliation(s)
- R Motyer
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin 9, Ireland
| | - H K Kok
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin 9, Ireland.,Department of Interventional Radiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - H Asadi
- Department of Radiology, Interventional Neuroradiology Service, Monash Medical Centre, Clayton, VIC, Australia.,Department of Radiology, Interventional Neuroradiology Service, Austin Hospital, Heidelberg, VIC, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, VIC, Australia
| | - A O'Hare
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin 9, Ireland
| | - P Brennan
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin 9, Ireland
| | - S Power
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin 9, Ireland
| | - S Looby
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin 9, Ireland
| | - P Nicholson
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin 9, Ireland
| | - D Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland.,Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin 9, Ireland
| | - S Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital, Dublin 7, Ireland.,School of Medicine, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
| | - M D Hill
- Department of Radiology, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - M Goyal
- Department of Radiology, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - J McManus
- Division of Ageing, Therapeutics and Rehabilitation, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - P O'Brien
- Department of Geriatric and Stroke Medicine, Naas General Hospital, Naas East, Naas, Kildare, Ireland
| | - J Thornton
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin 9, Ireland
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Evans JW, Graham BR, Pordeli P, Al-Ajlan FS, Willinsky R, Montanera WJ, Rempel JL, Shuaib A, Brennan P, Williams D, Roy D, Poppe AY, Jovin TG, Devlin T, Baxter BW, Krings T, Silver FL, Frei DF, Fanale C, Tampieri D, Teitelbaum J, Iancu D, Shankar J, Barber PA, Demchuk AM, Goyal M, Hill MD, Menon BK. Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial. AJNR Am J Neuroradiol 2017; 39:102-106. [PMID: 29191873 DOI: 10.3174/ajnr.a5462] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/15/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.
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Affiliation(s)
- J W Evans
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - B R Graham
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - P Pordeli
- Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - F S Al-Ajlan
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - R Willinsky
- Department of Medical Imaging (R.W., W.J.M.)
| | | | | | - A Shuaib
- Medicine (Neurology) (A.S.), University of Alberta, Edmonton, Alberta, Canada
| | - P Brennan
- Departments of Neuroradiology (P.B.)
| | - D Williams
- Geriatric and Stroke Medicine (D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - D Roy
- Departments of Radiology (D.R.)
| | - A Y Poppe
- Neurosciences (A.Y.P.), Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - T G Jovin
- Department of Neurology (T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - B W Baxter
- Department of Radiology (B.W.B), Erlanger Hospital, University of Tennessee, Chattanooga, Tennessee
| | | | - F L Silver
- Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - D F Frei
- Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado
| | - C Fanale
- Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - D Tampieri
- Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado
| | - J Teitelbaum
- Montreal Neurological Institute (J.T.), McGill University, Montreal, Quebec, Canada
| | - D Iancu
- Department of Radiology (D.I.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J Shankar
- Department of Neuroradiology (J.S.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - P A Barber
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M D Hill
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.) .,Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada.,Foothills Medical Centre (B.K.M.), Calgary, Alberta, Canada
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Tomsick TA, Liebeskind DS, Hill MD, von Kummer R, Goyal M, Broderick JP. Reply. AJNR Am J Neuroradiol 2017; 38:E44-E45. [PMID: 28473347 DOI: 10.3174/ajnr.a5200] [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: 11/07/2022]
Affiliation(s)
- T A Tomsick
- Department of Radiology University of Cincinnati Academic Health Center University Hospital Cincinnati, Ohio
| | - D S Liebeskind
- University of California, Los Angeles Stroke Center Los Angeles, California
| | - M D Hill
- Calgary Stroke Program Department of Clinical Neurosciences, Medicine Community Health Sciences, Hotchkiss Brain Institute University of Calgary, Foothills Hospital Calgary, Alberta, Canada
| | - R von Kummer
- Department of Neuroradiology Dresden University Stroke Center Universitätsklinikum Carl Gustav Carusan de Technischen Universität Dresden Dresden, Germany
| | - M Goyal
- Department of Radiology and Clinical Neurosciences University of Calgary Calgary, Alberta, Canada
| | - J P Broderick
- Department of Neurology University of Cincinnati Academic Health Center Cincinnati, Ohio
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21
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Al-Ajlan FS, Demchuk AM, Aviv RI, Rodriguez-Luna D, Molina C, Silva Y, Dzialowski I, Czlonkowska A A, Boulanger JM, Lum C, Gubitz G, Padma V, Roy J, Kase CS, Hill MD, Dowlatshahi D. Abstract WP372: The Acute ICH Growth Score: Simple and Accurate Predictor of Hematoma Expansion in Patients with Acute Intracerebral Hemorrhage. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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]
Abstract
Background and Purpose:
Acute intracerebral hemorrhage (ICH) hematoma expansion predicts high mortality and morbidity, occurring in a third of patients presenting with this condition. Recent studies correlated ultra-early hematoma growth and hematoma morphologic appearance with ICH expansion. Our purpose was to develop simple and clinically useful score that would predict ICH hematoma expansion accurately.
Methods:
This cohort included patients with primary or anticoagulation-associated ICH patients presenting <6 hours post ictus prospectively enrolled in the PREDICT study. Patients underwent baseline CT, CT angiography and 24-hour CT for hematoma expansion analysis. A risk score model was developed for predicting hematoma expansion (> 6 ml or > 33%). A 7-point acute ICH growth score was based on ultra-early hematoma growth > 5 mL/hour (yes=1), irregular morphology (yes=1), density heterogeneity (yes=1), presence of fluid-blood levels (yes=1), spot sign (yes=1), and use of anticoagulation (yes=2). Discrimination of the expansion score was assessed.
Results:
We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients. The 7-point acute ICH growth score demonstrated good discrimination for hematoma expansion>6 mL or 33% (area under the curve of 0.76). Median and significant HE are shown in the table below (p<0.001).
Conclusions:
In a multicenter prospective study, the ICH expansion score demonstrate good correlation with hematoma expansion, and included recently reported variables such as morphology and ultraearly growth.
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Affiliation(s)
- F S Al-Ajlan
- Ottawa Stroke Program, Univ of Ottawa, Ottawa, Canada
| | - A M Demchuk
- Calgary Stroke Program, Univ of Calgary, Calgary, Canada
| | - R I Aviv
- Med Imaging, Univ of Toronto, Toronto, Canada
| | - D Rodriguez-Luna
- Dept of Neurology, Vall d’Hebron Univ Hosp and Vall d’Hebron Rsch Institute, Barcelona, Spain, barcelona, Spain
| | - C Molina
- Calgary Stroke Program, Dept of Neurology, Vall d’Hebron Univ Hosp, Vall d’Hebron Rsch Institute, Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain., barcelona, Spain
| | - Y Silva
- Dept of Neurology, Dr Josep Trueta Univ Hosp, Institut d’Investigació Biomèdica Girona, Girona, Spain
| | - I Dzialowski
- Dept of Neurology, Elblandklinikum Meissen Academic Teaching Hosp of the Technische Univ, Dresden, Germany., Dresden, Germany
| | - A Czlonkowska A
- 2nd Dept of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland Dept of Experimental and Clinical Pharmacology, Med Univ of Warsaw, Warsaw, Poland, Warsaw, Poland
| | - J M Boulanger
- Dept of Medicine, Charles LeMoyne Hosp, Univ of Sherbrooke, Montreal, Canada., Montreal, Canada
| | - C Lum
- Dept of Diagnostic Imaging, Neuroradiology Section, Univ of Ottawa, Ottawa Hosp Rsch Institute, Ottawa, Canada., Ottawa, Canada
| | - G Gubitz
- Dept of Neurology, Dalhousie Univ, Halifax, Canada., Halifax, Canada
| | - V Padma
- Ottawa Stroke Program, Dept of Neurology, All India Institute of Med Sciences,, New Delhi, India
| | - J Roy
- AMRI Neurosciences Cntr, Mukundapurz, ,, Kolkata, Canada
| | - C S Kase
- Dept of Neurology, Boston Med Cntr, Boston, USA., Boston, MA
| | - M D Hill
- Calgary Stroke Program, Dept of Clinical Neurosciences, Hotchkiss Brain Institute,, Calgary, Canada
| | - D Dowlatshahi
- Dept of Medicine (Neurology), Univ of Ottawa and Ottawa Hosp Rsch Institute, Ottawa, Canada., Ottawa, Canada
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22
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Goyal M, Menon BK, Almekhlafi MA, Demchuk A, Hill MD. The Need for Better Data on Patients with Acute Stroke Who Are Not Treated Because of Unfavorable Imaging. AJNR Am J Neuroradiol 2017; 38:424-425. [PMID: 28104633 DOI: 10.3174/ajnr.a5094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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23
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Tomsick TA, Carrozzella J, Foster L, Hill MD, von Kummer R, Goyal M, Demchuk AM, Khatri P, Palesch Y, Broderick JP, Yeatts SD, Liebeskind DS. Endovascular Therapy of M2 Occlusion in IMS III: Role of M2 Segment Definition and Location on Clinical and Revascularization Outcomes. AJNR Am J Neuroradiol 2016; 38:84-89. [PMID: 27765740 DOI: 10.3174/ajnr.a4979] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/01/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Uncertainty persists regarding the safety and efficacy of endovascular therapy of M2 occlusions following IV tPA. We reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1-M2 segment anatomic features. MATERIALS AND METHODS Perfusion of any M2 branch distinguished M2-versus-M1 occlusion. Prespecified modified TICI and arterial occlusive lesion revascularization and clinical mRS 0-2 end points at 90 days for endovascular therapy-treated M2 occlusions were analyzed. Post hoc analyses of the relationship of outcomes to multiple baseline angiographic M2 and M1 subgroup characteristics were performed. RESULTS Of 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0-2 at 90 days, including 46.6% with modified TICI 2-3 reperfusion compared with 26.1% with modified TICI 0-1 reperfusion (risk difference, 20.6%; 95% CI, -1.4%-42.5%). mRS 0-2 outcome was associated with reperfusion for M2 trunk (n = 9) or M2 division (n = 42) occlusions, but not for M2 branch occlusions (n = 28). Of participants with trunk and division occlusions, 63.2% with modified TICI 2a and 42.9% with modified TICI 2b reperfusion achieved mRS 0-2 outcomes; mRS 0-2 outcomes for M2 trunk occlusions (33%) did not differ from distal (38.2%) and proximal (26.9%) M1 occlusions. CONCLUSIONS mRS 0-2 at 90 days was dependent on reperfusion for M2 trunk but not for M2 branch occlusions. For M2 division occlusions, good outcome with modified TICI 2b reperfusion did not differ from that in modified TICI 2a. M2 segment definition and occlusion location may contribute to differences in revascularization and good outcome between Interventional Management of Stroke III and other endovascular therapy studies.
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Affiliation(s)
- T A Tomsick
- From the Department of Radiology (T.A.T., J.C.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - J Carrozzella
- From the Department of Radiology (T.A.T., J.C.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - L Foster
- Department of Biostatistics, Bioinformatics, and Epidemiology (L.F., Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - M D Hill
- Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Medicine, Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - R von Kummer
- Department of Neuroradiology (R.v.K.), Dresden University Stroke Center, Universitätsklinikum Carl Gustav Carusan deTechnischen Universität Dresden, Dresden, Germany
| | - M Goyal
- Department of Radiology and Clinical Neurosciences (M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Medicine, Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - P Khatri
- Department of Neurology (P.K., J.P.B.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Y Palesch
- Department of Biostatistics, Bioinformatics, and Epidemiology (L.F., Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - J P Broderick
- Department of Neurology (P.K., J.P.B.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - S D Yeatts
- Department of Biostatistics, Bioinformatics, and Epidemiology (L.F., Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - D S Liebeskind
- University of California Los Angeles Stroke Center (D.S.L.), Los Angeles, California
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24
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Vagal A, Foster LD, Menon B, Livorine A, Shi J, Qazi E, Yeatts SD, Demchuk AM, Hill MD, Tomsick TA, Goyal M. Multimodal CT Imaging: Time to Treatment and Outcomes in the IMS III Trial. AJNR Am J Neuroradiol 2016; 37:1393-8. [PMID: 26988811 DOI: 10.3174/ajnr.a4751] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/22/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The importance of time in acute stroke is well-established. Using the Interventional Management of Stroke III trial data, we explored the effect of multimodal imaging (CT perfusion and/or CT angiography) versus noncontrast CT alone on time to treatment and outcomes. MATERIALS AND METHODS We examined 3 groups: 1) subjects with baseline CTP and CTA (CTP+CTA), 2) subjects with baseline CTA without CTP (CTA), and 3) subjects with noncontrast head CT alone. The demographics, treatment time intervals, and clinical outcomes in these groups were studied. RESULTS Of 656 subjects enrolled in the Interventional Management of Stroke III trial, 90 (13.7%) received CTP and CTA, 216 (32.9%) received CTA (without CTP), and 342 (52.1%) received NCCT alone. Median times for the CTP+CTA, CTA, and NCCT groups were as follows: stroke onset to IV tPA (120.5 versus 117.5 versus 120 minutes; P = .5762), IV tPA to groin puncture (77.5 versus 81 versus 91 minutes; P = .0043), groin puncture to endovascular therapy start (30 versus 38 versus 44 minutes; P = .0001), and endovascular therapy start to end (63 versus 46 versus 74 minutes; P < .0001). Compared with NCCT, the CTA group had better outcomes in the endovascular arm (OR, 2.12; 95% CI, 1.36-3.31; adjusted for age, NIHSS score, and time from onset to IV tPA). The CTP+CTA group did not have better outcomes compared with the NCCT group. CONCLUSIONS Use of CTA with or without CTP did not delay IV tPA or endovascular therapy compared with NCCT in the Interventional Management of Stroke III trial.
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Affiliation(s)
- A Vagal
- From the Department of Radiology (A.V., A.L., J.S., T.A.T.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - L D Foster
- Department of Public Health Sciences (L.D.F., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - B Menon
- Radiology (B.M, E.Q., M.G.), University of Calgary, Calgary Alberta, Canada
| | - A Livorine
- From the Department of Radiology (A.V., A.L., J.S., T.A.T.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - J Shi
- From the Department of Radiology (A.V., A.L., J.S., T.A.T.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - E Qazi
- Radiology (B.M, E.Q., M.G.), University of Calgary, Calgary Alberta, Canada
| | - S D Yeatts
- Department of Public Health Sciences (L.D.F., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | | | - M D Hill
- Departments of Neurology (A.M.D., M.D.H.)
| | - T A Tomsick
- From the Department of Radiology (A.V., A.L., J.S., T.A.T.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - M Goyal
- Radiology (B.M, E.Q., M.G.), University of Calgary, Calgary Alberta, Canada
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Tomsick TA, Foster LD, Liebeskind DS, Hill MD, Carrozella J, Goyal M, von Kummer R, Demchuk AM, Dzialowski I, Puetz V, Jovin T, Morales H, Palesch YY, Broderick J, Khatri P, Yeatts SD. Outcome Differences between Intra-Arterial Iso- and Low-Osmolality Iodinated Radiographic Contrast Media in the Interventional Management of Stroke III Trial. AJNR Am J Neuroradiol 2015; 36:2074-81. [PMID: 26228892 DOI: 10.3174/ajnr.a4421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/03/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracarotid arterial infusion of nonionic, low-osmolal iohexol contrast medium has been associated with increased intracranial hemorrhage in a rat middle cerebral artery occlusion model compared with saline infusion. Iso-osmolal iodixanol (290 mOsm/kg H2O) infusion demonstrated smaller infarcts and less intracranial hemorrhage compared with low-osmolal iopamidol and saline. No studies comparing iodinated radiographic contrast media in human stroke have been performed, to our knowledge. We hypothesized that low-osmolal contrast media may be associated with worse outcomes compared with iodixanol in the Interventional Management of Stroke III Trial (IMS III). MATERIALS AND METHODS We reviewed prospective iodinated radiographic contrast media data for 133 M1 occlusions treated with endovascular therapy. We compared 5 prespecified efficacy and safety end points (mRS 0-2 outcome, modified TICI 2b-3 reperfusion, asymptomatic and symptomatic intracranial hemorrhage, and mortality) between those receiving iodixanol (n = 31) or low-osmolal contrast media (n = 102). Variables imbalanced between iodinated radiographic contrast media types or associated with outcome were considered potential covariates for the adjusted models. In addition to the iodinated radiographic contrast media type, final covariates were those selected by using the stepwise method in a logistic regression model. Adjusted relative risks were then estimated by using a log-link regression model. RESULTS Of baseline or endovascular therapy variables potentially linked to outcome, prior antiplatelet agent use was more common and microcatheter iodinated radiographic contrast media injections were fewer with iodixanol. Relative risk point estimates are in favor of iodixanol for the 5 prespecified end points with M1 occlusion. The percentage of risk differences are numerically greater for microcatheter injections with iodixanol. CONCLUSIONS While data favoring the use of iso-osmolal iodixanol for reperfusion of M1 occlusion following IV rtPA are inconclusive, potential pathophysiologic mechanisms suggesting clinical benefit warrant further investigation.
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Affiliation(s)
- T A Tomsick
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - L D Foster
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - D S Liebeskind
- University of California, Los Angeles Stroke Center (D.S.L.), Los Angeles, California
| | - M D Hill
- Department of Radiology and Clinical Neurosciences (M.D.H., M.G.)
| | - J Carrozella
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - M Goyal
- Department of Radiology and Clinical Neurosciences (M.D.H., M.G.)
| | | | - A M Demchuk
- Calgary Stroke Program (A.M.D.), Department of Clinical Neurosciences/Medicine/Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - I Dzialowski
- Department of Neurology (I.D.), Elblandklinikum Meissen, Academic Teaching Hospital of Universitätsklinikum, Carl Gustav Carus Technische Universität Dresden, Meißen, Germany
| | - V Puetz
- Neurology (V.P.), Dresden University Stroke Center, Universitätsklinikum Carl Gustav Carus Technischen Universität Dresden, Dresden, Germany
| | - T Jovin
- The Stroke Institute (T.J.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
| | - H Morales
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - Y Y Palesch
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - J Broderick
- Department of Neurology (J.B., P.K.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - P Khatri
- Department of Neurology (J.B., P.K.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - S D Yeatts
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
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Tamm AS, McCourt R, Gould B, Kate M, Kosior JC, Jeerakathil T, Gioia LC, Dowlatshahi D, Hill MD, Coutts SB, Demchuk AM, Buck BH, Emery DJ, Shuaib A, Butcher KS. Cerebral Perfusion Pressure is Maintained in Acute Intracerebral Hemorrhage: A CT Perfusion Study. AJNR Am J Neuroradiol 2015; 37:244-51. [PMID: 26450534 DOI: 10.3174/ajnr.a4532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/14/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Although blood pressure reduction has been postulated to result in a fall in cerebral perfusion pressure in patients with intracerebral hemorrhage, the latter is rarely measured. We assessed regional cerebral perfusion pressure in patients with intracerebral hemorrhage by using CT perfusion source data. MATERIALS AND METHODS Patients with acute primary intracerebral hemorrhage were randomized to target systolic blood pressures of <150 mm Hg (n = 37) or <180 mm Hg (n = 36). Regional maps of cerebral blood flow, cerebral perfusion pressure, and cerebrovascular resistance were generated by using CT perfusion source data, obtained 2 hours after randomization. RESULTS Perihematoma cerebral blood flow (38.7 ± 11.9 mL/100 g/min) was reduced relative to contralateral regions (44.1 ± 11.1 mL/100 g/min, P = .001), but cerebral perfusion pressure was not (14.4 ± 4.6 minutes(-1) versus 14.3 ± 4.8 minutes(-1), P = .93). Perihematoma cerebrovascular resistance (0.34 ± 0.11 g/mL) was higher than that in the contralateral region (0.30 ± 0.10 g/mL, P < .001). Ipsilateral and contralateral cerebral perfusion pressure in the external (15.0 ± 4.6 versus 15.6 ± 5.3 minutes(-1), P = .15) and internal (15.0 ± 4.8 versus 15.0 ± 4.8 minutes(-1), P = .90) borderzone regions were all similar. Borderzone cerebral perfusion pressure was similar to mean global cerebral perfusion pressure (14.7 ± 4.7 minutes(-1), P ≥ .29). Perihematoma cerebral perfusion pressure did not differ between blood pressure treatment groups (13.9 ± 5.5 minutes(-1) versus 14.8 ± 3.4 minutes(-1), P = .38) or vary with mean arterial pressure (r = -0.08, [-0.10, 0.05]). CONCLUSIONS Perihematoma cerebral perfusion pressure is maintained despite increased cerebrovascular resistance and reduced cerebral blood flow. Aggressive antihypertensive therapy does not affect perihematoma or borderzone cerebral perfusion pressure. Maintenance of cerebral perfusion pressure provides physiologic support for the safety of blood pressure reduction in intracerebral hemorrhage.
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Affiliation(s)
- A S Tamm
- Department of Diagnostic Imaging (A.S.T., D.J.E.), University of Alberta, Edmonton, Alberta, Canada
| | - R McCourt
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - B Gould
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - M Kate
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - J C Kosior
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - T Jeerakathil
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - L C Gioia
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - D Dowlatshahi
- Division of Neurology (D.D.), University of Ottawa, Ottawa, Ontario, Canada
| | - M D Hill
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - S B Coutts
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - B H Buck
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - D J Emery
- Department of Diagnostic Imaging (A.S.T., D.J.E.), University of Alberta, Edmonton, Alberta, Canada
| | - A Shuaib
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - K S Butcher
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
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Choi PMC, Singh D, Trivedi A, Qazi E, George D, Wong J, Demchuk AM, Goyal M, Hill MD, Menon BK. Carotid Webs and Recurrent Ischemic Strokes in the Era of CT Angiography. AJNR Am J Neuroradiol 2015; 36:2134-9. [PMID: 26228877 DOI: 10.3174/ajnr.a4431] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/19/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Carotid webs may cause recurrent ischemic stroke. We describe the prevalence, demographics, clinical presentation, imaging features, histopathology, and stroke risk associated with this under-recognized lesion. MATERIALS AND METHODS A carotid web was defined on CTA as a thin intraluminal filling defect along the posterior wall of the carotid bulb just beyond the carotid bifurcation on oblique sagittal section CTA that was seen as a septum on axial CTA. Using a prospective case series from April 2013 to April 2014, we describe the demographics, spectrum of imaging features on CTA, and histopathology of these carotid webs. From a retrospective analysis of patients at our center from May 2012 to April 2013 who had a baseline head and neck CTA followed by a brain MR imaging within 1-2 days of the CTA, we determine the period prevalence of carotid webs and the prevalence of ipsilateral stroke on imaging. RESULTS In the prospective series, the mean age was 50 years (range, 41-55 years); 5/7 patients were women. Recurrent stroke was seen in 5/7 (71.4%) patients with the carotid web; time to recurrence ranged from 1 to 97 months. Histopathology suggested a high probability of fibromuscular dysplasia. In the retrospective series, carotid webs were seen in 7/576 patients for a hospital-based-period prevalence of 1.2% (95% CI, 0.4%-2.5%). Two of these 7 patients had acute stroke in the vascular territory of the carotid web. CONCLUSIONS A carotid web may contribute to recurrent ischemic stroke in patients with no other determined stroke mechanism. Intimal variant fibromuscular dysplasia is the pathologic diagnosis in most cases. The prevalence of carotid web is low, while the optimal management strategy remains unknown.
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Affiliation(s)
- P M C Choi
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.)
| | - D Singh
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.)
| | - A Trivedi
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.)
| | - E Qazi
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.)
| | - D George
- Departments of Pathology and Laboratory Medicine (D.G.)
| | - J Wong
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.) Radiology (J.W., A.M.D., M.G., M.D.H., B.K.M.)
| | - A M Demchuk
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.) Radiology (J.W., A.M.D., M.G., M.D.H., B.K.M.) Hotchkiss Brain Institute (A.M.D., M.G., M.D.H., B.K.M.), Calgary, Alberta, Canada
| | - M Goyal
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.) Radiology (J.W., A.M.D., M.G., M.D.H., B.K.M.) Hotchkiss Brain Institute (A.M.D., M.G., M.D.H., B.K.M.), Calgary, Alberta, Canada
| | - M D Hill
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.) Radiology (J.W., A.M.D., M.G., M.D.H., B.K.M.) Medicine and Community Health Science (M.D.H.), University of Calgary, Calgary, Alberta, Canada Hotchkiss Brain Institute (A.M.D., M.G., M.D.H., B.K.M.), Calgary, Alberta, Canada
| | - B K Menon
- From the Calgary Stroke Program, Department of Clinical Neuroscience (P.M.C.C., D.S., A.T., E.Q., J.W., A.M.D., M.G., M.D.H., B.K.M.) Radiology (J.W., A.M.D., M.G., M.D.H., B.K.M.) Hotchkiss Brain Institute (A.M.D., M.G., M.D.H., B.K.M.), Calgary, Alberta, Canada.
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Abstract
A 22-year-old female was seen in the emergency within one hour of acute onset of right sided headache followed by weakness of the left side of body. On neurological examination, she was mildly drowsy, had forced right gaze deviation, dysarthria, left hemiplegia and left hemisensory loss. Computed tomography (CT) scan revealed early ischemic changes in the right middle cerebral artery (MCA) territory. The CT angiography done showed evidence of dissection of the supraclinoid segment of the right internal carotid artery with reduced flow distally into the MCA, which was confirmed by a conventional angiogram. In view of the intracranial carotid dissection, the patient was not treated with intravenous tissue plasminogen activator. Magnetic resonance imaging (MRI) of the brain done on the next day revealed evidence of acute ischemic lesions in the right MCA and anterior cerebral artery territory on diffusion-weighted imaging (DWI), with normal brainstem. [Figure 1] A repeat MRI performed 13 days after ictus showed hyperintense signal on DWI in the right cerebral peduncle which was hypointense on apparent diffusion coefficient (ADC) map suggestive of Wallerian-like degeneration. [Figure 2] The signal changes were less conspicuous on T2-weighted images. She had antigravity strength in the left leg but remained weak in her left arm at one month.
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Affiliation(s)
- R N Sylaja
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Abstract
Background:Stroke incidence has fallen since 1950. Recent trends suggest that stroke incidence may be stabilizing or increasing. We investigated time trends in stroke occurrence and in-hospital morbidity and mortality in the Calgary Health Region.Methods:All patients admitted to hospitals in the Calgary Health Region between 1994 and 2002 with a primary discharge diagnosis code (ICD-9 or ICD-10) of stroke were included. In-hospital strokes were also included. Stroke type, date of admission, age, gender, discharge disposition (died, discharged) and in-hospital complications (pneumonia, pulmonary embolism, deep venous thrombosis) were recorded. Poisson and simple linear regression was used to model time trends of occurrence by stroke type and age-group and to extrapolate future time trends.Results:From 1994 to 2002, 11642 stroke events were observed. Of these, 9879 patients (84.8%) were discharged from hospital, 1763 (15.1%) died in hospital, and 591 (5.1%) developed in-hospital complications from pneumonia, pulmonary embolism or deep venous thrombosis. Both in-hospital mortality and complication rates were highest for hemorrhages. Over the period of study, the rate of stroke admission has remained stable. However, total numbers of stroke admission to hospital have faced a significant increase (p=0.012) due to the combination of increases in intracerebral hemorrhage (p=0.021) and ischemic stroke admissions (p=0.011). Sub-arachnoid hemorrhage rates have declined. In-hospital stroke mortality has experienced an overall decline due to a decrease in deaths from ischemic stroke, intracerebral hemorrhage and sub-arachnoid hemorrhage.Conclusion:Although age-adjusted stroke occurrence rates were stable from 1994 to 2002, this is associated with both a sharp increase in the absolute number of stroke admissions and decline in proportional in-hospital mortality. Further research is needed into changes in stroke severity over time to understand the causes of declining in-hospital stroke mortality rates.
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Affiliation(s)
- T S Field
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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30
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Abstract
Background:Prediction of outcome after stroke is important for triage decisions, prognostic estimates for family and for appropriate resource utilization. Prognostication must be timely and simply applied. Several scales have shown good prognostic value. In Calgary, the Orpington Prognostic Score (OPS) has been used to predict outcome as an aid to rehabilitation triage. However, the OPS has not been assessed at one week for predictive capability.Methods:Among patients admitted to a sub-acute stroke unit, OPS from the first week were examined to determine if any correlation existed between final disposition after rehabilitation and first week score. The predictive validity of the OPS at one week was compared to National Institute of Health Stroke Scale (NIHSS) score at 24 hours using logistic regression and receiver operator characteristics analysis. The primary outcome was final disposition after discharge from the stroke unit if the patient went directly home, or died, or from the inpatient rehabilitation unit.Results:The first week OPS was highly predictive of final disposition. However, no major advantage in using the first week OPS was observed when compared to 24h NIHSS score. Both scales were equally predictive of final disposition of stroke patients, post rehabilitation.Conclusion:The first week OPS can be used to predict final outcome. The NIHSS at 24h provides the same prognostic information.
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Affiliation(s)
- C J Wright
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, and Rehabilitation Services (Neurosciences Team-FMC), Calgary Health Region, Calgary, AB, Canada
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Stacey WM, Stewart CL, Floyd JP, Wilks TM, Moore AP, Bopp AT, Hill MD, Tandon S, Erickson AS. Resolution of Fission and Fusion Technology Integration Issues: An Upgraded Design Concept for the Subcritical Advanced Burner Reactor. NUCL TECHNOL 2014. [DOI: 10.13182/nt13-96] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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]
Affiliation(s)
- W. M. Stacey
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
| | - C. L. Stewart
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
| | - J.-P. Floyd
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
| | - T. M. Wilks
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
| | - A. P. Moore
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
| | - A. T. Bopp
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
| | - M. D. Hill
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
| | - S. Tandon
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
| | - A. S. Erickson
- Georgia Institute of Technology, Nuclear & Radiological Engineering Program Atlanta, Georgia 30332-0745
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Nambiar V, Sohn SI, Almekhlafi MA, Chang HW, Mishra S, Qazi E, Eesa M, Demchuk AM, Goyal M, Hill MD, Menon BK. CTA collateral status and response to recanalization in patients with acute ischemic stroke. AJNR Am J Neuroradiol 2013; 35:884-90. [PMID: 24371030 DOI: 10.3174/ajnr.a3817] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Collateral status at baseline is an independent determinant of clinical outcome among patients with acute ischemic stroke. We sought to identify whether the association between recanalization after intra-arterial acute stroke therapy and favorable clinical response is modified by the presence of good collateral flow assessed on baseline CTA. MATERIALS AND METHODS Data are from the Keimyung Stroke Registry, a prospective cohort study of patients with acute ischemic stroke from Daegu, South Korea. Patients with M1 segment MCA with or without intracranial ICA occlusions on baseline CTA from May 2004 to July 2009 who also had baseline MR imaging were included. Two readers blinded to all clinical information assessed baseline and follow-up imaging. Leptomeningeal collaterals on baseline CTA were assessed by consensus by use of the regional leptomeningeal score. RESULTS Among 84 patients (mean age, 65.2 ± 13.2 years; median NIHSS score, 14; interquartile range, 8.5), median time from stroke onset to initial MR imaging was 164 minutes. TICI 2b-3 recanalization was achieved in 38.1% of patients and mRS 0-2 at 90 days in 35.8% of patients. In a multivariable model, the interaction between collateral status and recanalization was significant. Only patients with intermediate or good collaterals who recanalized showed a statistically significant association with good clinical outcome (rate ratio = 3.8; 95% CI, 1.2-12.1). Patients with good and intermediate collaterals who did not achieve recanalization and patients with poor collaterals, even if they achieved recanalization, did not do well. CONCLUSIONS Patients with good or intermediate collaterals on CTA benefit from intra-arterial therapy, whereas patients with poor collaterals do not benefit from treatment.
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Affiliation(s)
- V Nambiar
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)
| | - S I Sohn
- Departments of Neurology (S.I.S.)
| | - M A Almekhlafi
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)Department of Internal Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia
| | - H W Chang
- Radiology (H.W.C.), Brain Research Institute, Keimyung University, Daegu, South Korea
| | - S Mishra
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)
| | - E Qazi
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)
| | - M Eesa
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)Radiology (M.E., A.M.D., M.G., M.D.H., B.K.M.)
| | - A M Demchuk
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)Radiology (M.E., A.M.D., M.G., M.D.H., B.K.M.)Hotchkiss Brain Institute (A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)Radiology (M.E., A.M.D., M.G., M.D.H., B.K.M.)Hotchkiss Brain Institute (A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M D Hill
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)Radiology (M.E., A.M.D., M.G., M.D.H., B.K.M.)Community Health Sciences (M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, CanadaHotchkiss Brain Institute (A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- From the Calgary Stroke Program, Departments of Clinical Neurosciences (V.N., M.A.A., S.M., E.Q., M.E., A.M.D., M.G., M.D.H., B.K.M.)Radiology (M.E., A.M.D., M.G., M.D.H., B.K.M.)Community Health Sciences (M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, CanadaHotchkiss Brain Institute (A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada.
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Abstract
A 54 year old man developed rhabdomyolysis one year after beginning treatment with a combination of lovastatin (an HMGCoA reductase inhibitor) and niacin. Muscle biopsy showed a severe necrotizing myopathy affecting both fibre types. Recovery occured gradually with cessation of medication. The spectrum of cholesterol lowering agent myopathy may include delayed cases of unusual severity.
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Affiliation(s)
- M D Hill
- University of Toronto Neuropathology, St. Michael's Hospital, ON, Canada
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Almekhlafi MA, Hill MD, Wiebe S, Goyal M, Yavin D, Wong JH, Clement FM. When is carotid angioplasty and stenting the cost-effective alternative for revascularization of symptomatic carotid stenosis? A Canadian health system perspective. AJNR Am J Neuroradiol 2013; 35:327-32. [PMID: 23928136 DOI: 10.3174/ajnr.a3682] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy. MATERIALS AND METHODS A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial. RESULTS In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (-0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy. CONCLUSIONS In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.
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Affiliation(s)
- M A Almekhlafi
- From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)
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Couillard P, Almekhlafi MA, Irvine A, Jetté N, Pow J, St Germaine-Smith C, Pillay N, Hill MD. Subacute seizure incidence in thrombolysis-treated ischemic stroke patients. Neurocrit Care 2012; 16:241-5. [PMID: 22160864 DOI: 10.1007/s12028-011-9657-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND To assess the incidence of seizures in acute ischemic stroke patients treated with chemical (tPA) thrombolysis. METHODS Retrospective study including all thrombolysis patients treated in Calgary between January 1, 2001, and October 31, 2006. Descriptive statistics and age/sex-adjusted P values were calculated. RESULTS Of 400 eligible patients (median age 74.0 years, range: 24-77), 16 (4%) developed post-stroke seizures: 10 (62.5%) within one week (early) and 6 (37.5%) after 1 week but within the hospital stay (late). Single-vessel anterior circulation involvement (93.8% vs. 87%, P = 0.34) and hemorrhage (37.5% vs. 20%, P = 0.15) were more common in those with compared to without seizures but did not reach statistical significance. Atrial fibrillation was more common in those with (56.3%) than without (36.1%) seizures (P = 0.04). Death during admission was more likely (P = 0.03) in those who sustained seizures (37.5%) compared to those without seizures (17.6%). CONCLUSIONS In this cohort of tPA-treated patients, post-stroke seizures were associated with atrial fibrillation and early mortality.
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Affiliation(s)
- P Couillard
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB T2N 2T9, Canada.
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Menon BK, Smith EE, Modi J, Patel SK, Bhatia R, Watson TWJ, Hill MD, Demchuk AM, Goyal M. Regional leptomeningeal score on CT angiography predicts clinical and imaging outcomes in patients with acute anterior circulation occlusions. AJNR Am J Neuroradiol 2011; 32:1640-5. [PMID: 21799045 DOI: 10.3174/ajnr.a2564] [Citation(s) in RCA: 249] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The regional leptomeningeal score is a strong and reliable imaging predictor of good clinical outcomes in acute anterior circulation ischemic strokes and can therefore be used for imaging based patient selection. Efforts to determine biological determinants of collateral status are needed if techniques to alter collateral behavior and extend time windows are to succeed. MATERIALS AND METHODS This was a retrospective Institutional Review Board-approved study of patients with acute ischemic stroke and M1 middle cerebral artery+/- intracranial internal carotid artery occlusion at our center from 2003 to 2009. The rLMC score is based on scoring pial and lenticulostriate arteries (0, no; 1, less; 2, equal or more prominent compared with matching region in opposite hemisphere) in 6 ASPECTS regions (M1-6) plus anterior cerebral artery region and basal ganglia. Pial arteries in the Sylvian sulcus are scored 0, 2, or 4. Good clinical outcome was defined as mRS ≤ 2 at 90 days. RESULTS The analysis included 138 patients: 37.6% had a good (17-20), 40.5% a medium (11-16), and 21.7% a poor (0-10) rLMC score. Interrater reliability was high, with an intraclass correlation coefficient of 0.87 (95% CI, 0.77%-0.95%). On univariate analysis, no single vascular risk factor was associated with the presence of poor rLMCs (P ≥ .20 for all comparisons). In multivariable analysis, the rLMC score (good versus poor: OR, 16.7; 95% CI, 2.9%-97.4%; medium versus poor: OR, 9.2, 95% CI, 1.7%-50.6%), age (< 80 years), baseline ASPECTS (≥ 8), and clot burden score (≥ 8) were independent predictors of good clinical outcome. CONCLUSIONS The rLMC score is a strong imaging parameter on CT angiography for predicting clinical outcomes in patients with acute ischemic strokes.
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Affiliation(s)
- B K Menon
- Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada
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Eesa M, Menon BK, Hill MD, Demchuk A, Goyal M. Achieving faster recanalization times by IA thrombolysis in acute ischemic stroke: where should we direct our efforts? Interv Neuroradiol 2011; 17:228-34. [PMID: 21696664 DOI: 10.1177/159101991101700215] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 03/11/2011] [Indexed: 11/16/2022] Open
Abstract
Faster recanalization correlates with better outcomes in acute ischemic stroke. We analyzed times from arrival in ER to end of treatment in patients undergoing endovascular treatment for acute ischemic stroke at our institution.We retrospectively studied patients who underwent IA procedures for stroke from 2005 to 2009 noting the times of arrival to ER, CT scan, arrival to DSA, arterial puncture and recanalization from our endovascular database. A subgroup analysis was performed based on administration of GA, use of mechanical devices and whether the procedure was performed during regular hours or after hours.Of 101 patients, 53 were male, with a median age of 66 years (range 18-87). There were 81 anterior circulation strokes. Median ER to CT time was 22 min (2-1025), CT to DSA arrival time 80 min (range 4-990), DSA arrival to puncture time 24 min (range 0-75) and puncture to recanalization time 84 min (range 11-206). 23.3% of patients had an ER to CT time interval of > 60 min and 71.3 % had a CT to DSA time interval of > 60 min contributing to significant in-hospital delays. For subgroup analysis the Mann-Whitney test was used. No significant differences in CT to DSA arrival (p=0.8), DSA arrival to puncture (p=0.1) and puncture to recanalization (p=0.59) times were noted between patients with and without GA. No significant difference was noted in puncture to recanalization times with or without device (p=0.78). 39 cases were done during regular (R) hours and 62 after (A) hours. Median ER to CT time (R=18 min, A = 27 min, p 0.02), CT to DSA arrival time (R=64 min, A=90 min, p 0.004) and DSA arrival to puncture time (R=18 min, A=25 min, p 0.003) was significantly higher after hours.ER to CT and CT to DSA arrival times in patients undergoing endovascular stroke therapy show wide variability and therefore, considerable scope for reduction. Time differences during regular and after hours should serve as a reminder to make efforts to reduce overall ischemic times in spite of staffing patterns and resource availability.
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Affiliation(s)
- M Eesa
- Department of Diagnostic Imaging, University of Calgary, Canada
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Coutts SB, Sylaja PN, Choi YB, Al-Khathami A, Sivakumar C, Jeerakathil TJ, Sarma PS, Hill MD. The ASPIRE approach for TIA risk stratification. Can J Neurol Sci 2011; 38:78-81. [PMID: 21156434] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND The risk of stroke after transient ischemic attack (TIA) is elevated in the days to weeks after TIA. A variety of prediction rules to predict stroke risk have been suggested. In Alberta a triage algorithm to facilitate urgent access based on risk level was agreed upon for the province. Patients with ABCD2 score ≥ 4, or motor or speech symptoms lasting greater than five minutes, or with atrial fibrillation were considered high risk (the ASPIRE approach). We assessed the ability of the ASPIRE approach to identify patients at risk for stroke. METHODS We retrospectively reviewed charts from 573 consecutive patients diagnosed with TIA in Foothills Hospital emergency room from 2002 through 2005. We recorded clinical and event details and identified the risk of stroke at three months. RESULTS Among 573 patients the 90-day risk of stroke was 4.7% (95% CI 3.0%, 6.4%). 78% of the patients were identified as high risk using this approach. In patients defined as high risk on the ASPIRE approach there was a 6.3% (95% CI 4.2%, 8.9%) risk of stroke. In patients defined as low risk using the ASPIRE approach there were no recurrent strokes (100% negative predictive value). In contrast, two patients with low ABCD2 scores (ABCD2 score < 4) suffered recurrent strokes. CONCLUSION The ASPIRE approach has a perfect negative predictive value in the population in predicting stroke. However, this high sensitivity comes at a cost of identifying most patients as high risk.
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Affiliation(s)
- S B Coutts
- Calgary Stroke Program, University of Calgary, Calgary Department of Clinical Neurosciences, University of Calgary, Calgary
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Eesa M, Hill MD, Al-Khathaami A, Al-Zawahmah M, Sharma P, Menon BK, Tymchuk S, Demchuk AM, Goyal M. Role of CT angiographic plaque morphologic characteristics in addition to stenosis in predicting the symptomatic side in carotid artery disease. AJNR Am J Neuroradiol 2010; 31:1254-60. [PMID: 20360336 DOI: 10.3174/ajnr.a2078] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Atherosclerotic disease of the carotid artery is an important cause of ischemic stroke. We evaluated carotid plaque morphologic features by using CTA in addition to stenosis in the setting of symptomatic hemispheric TIA/stroke to identify factors that may predict plaque activity. MATERIALS AND METHODS Six hundred seventy-three patients (408 men; ages, 18-91 years; mean, 65.8 +/- 15.2 years) presenting with hemispheric ischemic symptoms and having a CTA that included imaging of both carotid arteries within 24 hours were studied. Scans were interpreted for morphologic features, such as plaque length and width, attenuation, shape, surface, presence and degree of calcification, and ILT in addition to stenosis. RESULTS Univariable analysis showed that carotid occlusions (P = .01, OR = 5.27), high-grade stenosis (70%-99%) (P = .06, OR = 1.8), and the presence of ILT (P = .01, OR = 4.33) were highly predictive of the symptomatic side. Smooth plaque (P = .01, OR = 0.73) and extensive calcification (P = .03, OR = 0.72) were more commonly associated with the asymptomatic side. There was no correlation between plaque hypoattenuation (P = .7, OR = 1.06) or ulcerated plaque (P = .74, OR = 0.955) in predicting the symptomatic side. In a multivariable logistic regression model, the presence of ILT was still found to be significantly associated with the symptomatic side (P = .048, OR = 3.1) and the presence of extensive calcification, with the asymptomatic carotid artery (P = .047, OR = 0.69). CONCLUSIONS In addition to higher stenosis grades, the presence of ILT is highly predictive of the symptomatic side in carotid disease. Smooth plaque and extensive calcification seem to afford a protective effect. This information may be useful in radiologic risk stratification in carotid disease in addition to the current evidence available based on stenosis criteria alone.
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Affiliation(s)
- M Eesa
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
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Tomsick TA, Khatri P, Jovin T, Demaerschalk B, Malisch T, Demchuk A, Hill MD, Jauch E, Spilker J, Broderick JP. Equipoise among recanalization strategies. Neurology 2010; 74:1069-76. [PMID: 20350981 DOI: 10.1212/wnl.0b013e3181d76b8f] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Modern acute ischemic stroke therapy is based on the premise that recanalization and subsequent reperfusion are essential for the preservation of brain tissue and favorable clinical outcomes. We outline key issues that we think underlie equipoise regarding the comparative clinical efficacy of IV recombinant tissue-type plasminogen activator (rt-PA) and intra-arterial (IA) reperfusion therapies for acute ischemic stroke. On the one hand, IV rt-PA therapy has the benefit of speed with presumed lower rates of recanalization of large artery occlusions as compared to IA methods. More recent reports of major arterial occlusions treated with IV rt-PA, as measured by transcranial Doppler and magnetic resonance angiography, demonstrate higher rates of recanalization. Conversely, IA therapies report higher recanalization rates, but are hampered by procedural delays and risks, even failing to be applied at all in occasional patients where time to reperfusion remains a critical factor. Higher rates of recanalization in IA trials using clot-removal devices have not translated into improved patient functional outcome as compared to trials of IV therapy. Combined IV-IA therapy promises to offer advantages of both, but perhaps only when applied in the timeliest of fashions, compared to IV therapy alone. Where equipoise exists, randomizing subjects to either IV rt-PA therapy or IV therapy followed by IA intervention, while incorporating new interventions into the study design, is a rational and appropriate research approach.
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Affiliation(s)
- T A Tomsick
- Department of Neurology, UC Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH 45267-0525, USA.
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Abstract
OBJECTIVE Stroke thrombolysis may have a differential effect by sex. We sought to examine the relationship between sex and outcome after thrombolysis. METHODS This is a retrospective cohort study of stroke patients from the Registry of Canadian Stroke Network phase 1 (June 2001-February 2002) and phase 2 (June 2002-December 2002). Variables including demographics, history, clinical data, process measures, and outcome were analyzed. The primary outcomes were the Stroke Impact Scale-16 score (SIS-16) and mortality at 6 months. We compared the outcomes of the thrombolyzed and nonthrombolyzed cohorts and examined the data for a tissue plasminogen activator (tPA)-by-sex interaction on the 2 primary outcomes. RESULTS The overall proportion of patients who achieved an excellent outcome (SIS-16 >75) was not different by gender. However, the proportion of patients achieving an excellent outcome in the non-tPA cohort was much greater in males, with an absolute risk difference of 11.8%. A multiplicative treatment by sex interaction was evident (p = 0.054). This interaction was not present for stroke case fatality. CONCLUSIONS Women fared poorly compared to men in the placebo groups, but this negative prognostic sex effect was neutralized by thrombolysis.
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Affiliation(s)
- N Shobha
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, T2N 2T9, Canada
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Coutts SB, O'Reilly C, Hill MD, Steffenhagen N, Poppe AY, Boyko MJ, Puetz V, Demchuk AM. Computed tomography and computed tomography angiography findings predict functional impairment in patients with minor stroke and transient ischaemic attack. Int J Stroke 2010; 4:448-53. [PMID: 19930054 DOI: 10.1111/j.1747-4949.2009.00346.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Abnormalities on acute magnetic resonance imaging predict outcome in minor stroke and transient ischaemic attack patients. We hypothesised that noncontrast computed tomography and computed tomography angiography findings in minor stroke and transient ischaemic attack patients would also predict functional outcome. METHODS We analysed consecutive patients with a transient ischaemic attack or a minor stroke with an National Institute of Health Stroke Scale <or=3 who were assessed with a noncontrast computed tomography and CT angiography of the circle of Willis and neck within 24 h of symptom onset. We assessed the association between clinical or imaging features and functional impairment on the modified Rankin Scale (mRS >or=2 ) at 90 days. RESULTS Among 457 patients, the median baseline National Institute of Health Stroke Scale score was 1. Median time from symptom onset to noncontrast computed tomography was 278 min (interquartile range 151-505) and median delay from noncontrast computed tomography to CT angiography was 3 min (interquartile range 0-13). At 90 days, 57 patients (12.5%) had a mRS >or=2. Clinical factors that were associated with functional impairment were age >or=60 years (RR 2.05 CI(95) 1.16-3.64) and baseline National Institute of Health Stroke Scale score >0 (RR 3.23 1.72-6.06). All the assessed computed tomography parameters (acute stroke on noncontrast computed tomography and intracranial or extracranial stenosis or occlusion) were individually predictive of functional impairment. A composite computed tomography imaging 'at risk' metric, defined by acute stroke on noncontrast computed tomography, Circle of Willis intracranial vessel occlusion or >or=50% stenosis, extracranial occlusion or >or=50% stenosis, was associated with poorer outcome (RR 2.92 CI(95) 1.81-4.71). CONCLUSIONS The presence of an acute stroke on noncontrast computed tomography or an intracranial or extracranial occlusion or stenosis was associated with an increased risk of functional impairment. Multi-modal computed tomography could be used to identify high-risk transient ischaemic attack or minor stroke patients.
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Affiliation(s)
- S B Coutts
- Seaman Family MR Research Centre, Foothills Medical Centre, Calgary Health Region, AB, Canada.
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Abstract
The introduction of brain imaging with computed tomography revolutionised the treatment of patients with acute ischaemic stroke. With the visual differentiation of haemorrhagic stroke from ischaemic stroke, thrombolytic therapy became feasible. The Alberta Stroke Program Early CT Score was devised to quantify the extent of early ischaemic changes in the middle cerebral artery territory on noncontrast computed tomography. With its systematic approach, the score is simple and reliable. However, the assessment of early ischaemic changes and Alberta Stroke Program Early CT scoring require training. The Alberta Stroke Program Early CT Score is a strong predictor of functional outcome. Furthermore, the effectiveness of intraarterial thrombolysis in patients with middle cerebral artery occlusion shows effect modification by the Alberta Stroke Program Early CT Score. This review summarises the Alberta Stroke Program Early CT Score methodology. We illustrate current knowledge regarding Alberta Stroke Program Early CT Score applied to clinical trials and comment on how Alberta Stroke Program Early CT Score may facilitate clinical treatment decision making and future trial design. Moreover, we introduce a modification of the Alberta Stroke Program Early CT Score methodology that disregards isolated cortical swelling, i.e. focal brain swelling without associated parenchymal hypoattenuation, as early ischaemic changes in the Alberta Stroke Program Early CT Score system.
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Affiliation(s)
- V. Puetz
- Department of Neurology, Dresden University Stroke Centre, University of Technology Dresden, Dresden, Germany
- Department of Clinical Neurosciences, Calgary Stroke Program, University of Calgary, Calgary, AB, Canada
| | - I. Dzialowski
- Department of Neurology, Dresden University Stroke Centre, University of Technology Dresden, Dresden, Germany
- Department of Clinical Neurosciences, Calgary Stroke Program, University of Calgary, Calgary, AB, Canada
| | - M. D. Hill
- Department of Clinical Neurosciences, Calgary Stroke Program, University of Calgary, Calgary, AB, Canada
| | - A. M. Demchuk
- Department of Clinical Neurosciences, Calgary Stroke Program, University of Calgary, Calgary, AB, Canada
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Davidoff AW, Hill MD, Cramer SC, Yang Y, Moore A. Open labeled, uncontrolled pharmacokinetic study of a single intramuscular hCG dose in healthy male volunteers. Int J Clin Pharmacol Ther 2009; 47:516-524. [PMID: 19640360] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
The current study was designed to compare blood and cerebrospinal fluid (CSF) pharmacokinetic characteristics of two forms of human chorionic gonadotropin (hCG): Pregnyl(R), derived from human urine, and Ovitrelle(R) a recombinant form. Two separate groups, each with six older male human subjects, were dosed with either form of the drug at 10,000 IU intramuscularly (IM), and followed over a 36-hour period. No significant difference in the serum level of hCG was observed for either preparation of hCG (Peak serum conc.: 316 +/- 53 vs. 270 +/- 60 at 12 hours, 311 +/- 38 vs. 321 +/- 60 IU/l at 24 hours; AUC: 10,053 +/- 1,268 vs. 8,793 +/- 1,768, Pregnyl and Ovitrelle, mean +/- SD, respectively). Additionally, both forms of circulating hCG distributed to the central nervous system (CNS) as manifest by an increased number of subjects whose CSF samples showed detectable levels of hCG in their CSF over a 36-hour period. Similarly, there was no significant difference between the two forms when distribution to the CSF was compared at 36 hours (2.0 and 1.2 IU/l; range 1.9 - 2.1 and 1 - 1.4 IU/l for Pregnyl and Ovitrelle, resp.). This preliminary study in normal human volunteers suggests that the two forms of hCG tested, Ovitrelle(R) and Pregnyl(R), when administered IM, distribute in a similar fashion into the circulation and CSF. Consequently, we conclude that these two drugs demonstrate no statistical significant difference with respect to the CSF.
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Affiliation(s)
- A W Davidoff
- Stem Cell Therapeutics Corp., Calgary, Alberta, Canada.
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Aichner FT, Topakian R, Alberts MJ, Bhatt DL, Haring HP, Hill MD, Montalescot G, Goto S, Touzé E, Mas JL, Steg PG, Röther J. High cardiovascular event rates in patients with asymptomatic carotid stenosis: the REACH registry. Eur J Neurol 2009; 16:902-8. [DOI: 10.1111/j.1468-1331.2009.02614.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Puetz V, Sylaja PN, Hill MD, Coutts SB, Dzialowski I, Becker U, Gahn G, von Kummer R, Demchuk AM. CT angiography source images predict final infarct extent in patients with basilar artery occlusion. AJNR Am J Neuroradiol 2009; 30:1877-83. [PMID: 19643923 DOI: 10.3174/ajnr.a1723] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) is a 10-point grading system to quantify ischemic changes in the posterior circulation. We analyzed whether pc-ASPECTS on CT angiography (CTA) source images (CTASI) predicted the final infarct extent and hemorrhagic transformation (HT) rate in patients with basilar artery occlusion. MATERIALS AND METHODS A pc-ASPECTS score of 10 indicates absence of visible ischemic changes in the posterior circulation, and pc-ASPECTS score of 0 indicates ischemic changes in the midbrain, pons, and bilateral thalami, posterior circulation territories, and cerebellar hemispheres. We retrospectively studied patients with basilar artery occlusion on CTA within 24 hours from symptom onset. We applied pc-ASPECTS to noncontrast CT (NCCT), CTASI, and follow-up images by 3-reader-consensus and assessed HT on follow-up images. We calculated Spearman correlation coefficients and performed linear regression analysis. Final infarct extent and HT rates were compared across dichotomized CTASI pc-ASPECTS groups (>/= 8 vs < 8). RESULTS Among 43 patients, median (range) onset to CTA time was 5.0 hours (range, 0.7-24 hours). Pc-ASPECTS on CTASI (r = 0.75; P < .001) but not NCCT (r = 0.29; P = .063) correlated with pc-ASPECTS on follow-up scans. Linear regression demonstrated a significant positive relationship between pc-ASPECTS on CTASI and follow-up scans (R(2) = 0.58; P < 01). Median follow-up pc-ASPECTS was lower in patients with a CTASI pc-ASPECTS < 8 compared with patients with a CTASI pc-ASPECTS of 8 or more, respectively (P < .001). HT rates were 27.3% vs 9.5%, respectively (P = .24). None of 8 patients without thrombolysis had HT on follow-up scans. CONCLUSIONS The extent of hypoattenuation on CTASI predicts the final infarct extent in patients with basilar artery occlusion.
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Affiliation(s)
- V Puetz
- Department of Neurology and Neuroradiology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany.
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Almekhlafi MA, Wilton SB, Rabi DM, Ghali WA, Lorenzetti DL, Hill MD. Recurrent cerebral ischemia in medically treated patent foramen ovale: a meta-analysis. Neurology 2009; 73:89-97. [PMID: 19439720 DOI: 10.1212/wnl.0b013e3181aa2a19] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Among patients with a patent foramen ovale (PFO) and a prior cryptogenic ischemic stroke or TIA, the absolute and relative risk of recurrent events is unclear. METHODS We conducted a systematic review and meta-analysis of clinical studies in any language published up to February 2008. We included studies reporting original data on recurrent cerebrovascular events in patients with prior cryptogenic stroke or TIA and PFO. Two authors independently extracted data and evaluated study quality. RESULTS We identified 15 eligible studies, four with a non-PFO comparison group. In these four studies, the pooled relative risk (RR) for recurrent ischemic stroke or TIA in patients with vs without a PFO was 1.1 (95% confidence interval [CI] 0.8 to 1.5). For ischemic stroke, the pooled RR was 0.8 (95% CI 0.5 to 1.3). We tabulated the absolute rate of recurrent events in all 15 studies. The pooled absolute rate of recurrent ischemic stroke or TIA in patients with PFO was 4.0 events per 100 person-years (95% CI 3.0 to 5.1) while the rate of recurrent ischemic stroke was 1.6 events per 100 person-years (95% CI 1.1 to 2.1). CONCLUSIONS In medically treated patients with prior cryptogenic stroke, while the absolute rate of recurrent events is variable, available evidence does not support an increased relative risk of recurrent ischemic events in those with vs without a patent foramen ovale. Patent foramen ovale closure in these patients cannot be recommended until the results of ongoing clinical trials are reported.
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Affiliation(s)
- M A Almekhlafi
- Room 1242A, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, T2N 2T9 Canada
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Freeman WD, Hill MD, Feng Zhu H. STROKE: THE ELIXHAUSER INDEX FOR COMORBIDITY ADJUSTMENT OF IN-HOSPITAL CASE FATALITY. Neurology 2009; 72:1191; author reply 1191. [DOI: 10.1212/01.wnl.0000346460.05831.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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