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Walter J, Alhalabi OT, Schönenberger S, Ringleb P, Vollherbst DF, Möhlenbruch M, Unterberg A, Neumann JO. Prior Thrombectomy Does Not Affect the Surgical Complication Rate of Decompressive Hemicraniectomy in Patients with Malignant Ischemic Stroke. Neurocrit Care 2024; 40:698-706. [PMID: 37639204 PMCID: PMC10959817 DOI: 10.1007/s12028-023-01820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Even though mechanical recanalization techniques have dramatically improved acute stroke care since the pivotal trials of decompressive hemicraniectomy for malignant courses of ischemic stroke, decompressive hemicraniectomy remains a mainstay of malignant stroke treatment. However, it is still unclear whether prior thrombectomy, which in most cases is associated with application of antiplatelets and/or anticoagulants, affects the surgical complication rate of decompressive hemicraniectomy and whether conclusions derived from prior trials of decompressive hemicraniectomy are still valid in times of modern stroke care. METHODS A total of 103 consecutive patients who received a decompressive hemicraniectomy for malignant middle cerebral artery infarction were evaluated in this retrospective cohort study. Surgical and functional outcomes of patients who had received mechanical recanalization before surgery (thrombectomy group, n = 49) and of patients who had not received mechanical recanalization (medical group, n = 54) were compared. RESULTS The baseline characteristics of the two groups did significantly differ regarding preoperative systemic thrombolysis (63.3% in the thrombectomy group vs. 18.5% in the medical group, p < 0.001), the rate of hemorrhagic transformation (44.9% vs. 24.1%, p = 0.04) and the preoperative Glasgow Coma Score (median of 7 in the thrombectomy group vs. 12 in the medical group, p = 0.04) were similar to those of prior randomized controlled trials of decompressive hemicraniectomy. There was no significant difference in the rates of surgical complications (10.2% in the thrombectomy group vs. 11.1% in the medical group), revision surgery within the first 30 days after surgery (4.1% vs. 5.6%, respectively), and functional outcome (median modified Rankin Score of 4 at 5 and 14 months in both groups) between the two groups. CONCLUSIONS A prior mechanical recanalization with possibly associated systemic thrombolysis does not affect the early surgical complication rate and the functional outcome after decompressive hemicraniectomy for malignant ischemic stroke. Patient characteristics have not changed significantly since the introduction of mechanical recanalization; therefore, the results from former large randomized controlled trials are still valid in the modern era of stroke care.
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Affiliation(s)
- Johannes Walter
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - O T Alhalabi
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - S Schönenberger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - D F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - A Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - J-O Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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2
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Fisch U, von Felten S, Wiencierz A, Jansen O, Howard G, Hendrikse J, Halliday A, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Becquemin JP, Algra A, Rothwell P, Ringleb P, Mas JL, Brown M, Brott T, Bonati L. Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.05.016] [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: 10/21/2022]
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3
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Yu WM, Abdul-Rahim AH, Cameron AC, Kõrv J, Sevcik P, Toni D, Lees KR, Wahlgren N, Ahmed N, Caso V, Roffe C, Kobayashi A, Tsivgoulis G, Toni D, Ford G, Lees K, Ringleb P. The Incidence and Associated Factors of Early Neurological Deterioration After Thrombolysis. Stroke 2020; 51:2705-2714. [DOI: 10.1161/strokeaha.119.028287] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background and purpose:
Early neurological deterioration (END) after stroke onset may predict severe outcomes. Estimated rates of END after intravenous thrombolysis among small patient samples have been reported up to 29.8%. We studied the incidence and factors associated with END among patients following intravenous thrombolysis.
Methods:
We analyzed SITS-International Stroke Thrombolysis registry patients with known outcomes enrolled in 2010 to 2017. END was defined as an increase in National Institutes of Health Stroke Scale score ≥4 or death within 24 hours from baseline National Institutes of Health Stroke Scale. We determined the incidence of END and used logistic regression models to inspect its associated factors. We adjusted for variables found significant in univariate analyses (
P
<0.05). Main outcomes were incidence of END, associated predictors of END, ordinal day-90 mRS, and day-90 mortality.
Results:
We excluded 53 539 patients and included 50 726 patients. The incidence of END was 3415/50 726 (6.7% [95% CI, 6.5%–7.0%]). Factors independently associated with END on multivariate analysis were intracerebral hemorrhage (OR, 3.23 [95% CI, 2.96–3.54],
P
<0.001), large vessel disease (LVD) with carotid stenosis (OR, 2.97 [95% CI, 2.45–3.61],
P
<0.001), other LVD (OR, 2.41 [95% CI, 2.03–2.88],
P
<0.001), and ischemic stroke versus transient ischemic attack (TIA)/stroke mimics (OR, 16.14 [95% CI, 3.99–65.3],
P
<0.001). END was associated with worse outcome on ordinal mRS: adjusted OR 2.48 (95% CI, 2.39–2.57,
P
<0.001) by day-90 compared with no END. The adjusted OR for day-90 mortality was 9.70 (95% CI, 8.36–11.26,
P
<0.001).
Conclusions:
The routinely observed rate of END reflected by real-world data is low, but END greatly increases risk of disability and mortality. Readily identifiable factors predict END and may help with understanding causal mechanisms to assist prevention of END.
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Affiliation(s)
- Wai M. Yu
- Institute of Cardiovascular and Medical Sciences (W.M.Y., A.C.C.), University of Glasgow, United Kingdom
| | - Azmil H. Abdul-Rahim
- Institute of Neuroscience and Psychology (A.H.A.-R.), University of Glasgow, United Kingdom
| | - Alan C. Cameron
- Institute of Cardiovascular and Medical Sciences (W.M.Y., A.C.C.), University of Glasgow, United Kingdom
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Estonia (J.K.)
| | - Petr Sevcik
- Department of Neurology, Faculty of Medicine in Pilsen-Charles University (P.S.)
- Department of Neurology-University Hospital Pilsen, Plzen, Czech Republic (P.S.)
| | - Danilo Toni
- Department of Human Neurosciences, University La Sapienza, Rome, Italy (D.T.)
| | - Kennedy R. Lees
- School of Medicine, Dentistry and Nursing (K.R.L.), University of Glasgow, United Kingdom
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4
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Busetto L, Stang C, Hoffmann J, Amiri H, Seker F, Purrucker J, Ringleb PA, Nagel S, Bendszus M, Wick W, Gumbinger C. Patient-centredness in acute stroke care - a qualitative study from the perspectives of patients, relatives and staff. Eur J Neurol 2020; 27:1638-1646. [PMID: 32337811 DOI: 10.1111/ene.14283] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/18/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Although patient-centredness is considered a key component of high-quality neurological care, it is unclear to what extent it can or should be implemented during the acute phase. Using acute stroke as an example, the aim was to identify critical junctures for patient-centredness along the acute care pathway from the perspectives of patients, relatives and staff. METHODS A qualitative multi-method study was conducted including 27 non-participant observations and 37 semi-structured interviews with patients, relatives and staff. Junctures were defined as critical when mentioned (as problematic) in two or three information sources (i.e. observations, staff interviews, or patient and relative interviews), as potentially critical when mentioned in one, and as uncritical when not mentioned. RESULTS Post-procedure communication after thrombectomy, patients' stay at the stroke unit and decision-making around transfer, discharge and rehabilitation were identified as critical junctures for patient-centredness. Arrival at the emergency department and the (thrombectomy) treatment itself were identified as uncritical junctures, whilst history-taking and treatment preparation, the treatment decision and patients' stay at the intensive care unit were identified as potentially critical junctures. CONCLUSIONS In acute stroke care, patients, relatives and staff prioritize fast over patient-centred decision-making in the most time-critical phases, especially before and during treatment. This is reversed after the procedure, when difficulties arise implementing a patient-centred approach in clinical practice. To improve patient-centredness where it is most needed, clear guidelines and accessible resources are recommended. Future research should investigate whether insights from acute phases of stroke care are applicable to other neurological conditions as well.
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Affiliation(s)
- L Busetto
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Stang
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - J Hoffmann
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - H Amiri
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - F Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - J Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - P A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - S Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - W Wick
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany
| | - C Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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5
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Schneider C, Okun JG, Schwarz KV, Hauke J, Zorn M, Nürnberg C, Ungerer M, Ringleb PA, Mundiyanapurath S. Trimethylamine-N-oxide is elevated in the acute phase after ischaemic stroke and decreases within the first days. Eur J Neurol 2020; 27:1596-1603. [PMID: 32282978 DOI: 10.1111/ene.14253] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Trimethylamine-N-oxide (TMAO) is a biomarker of the gut microbiome and correlates with the risk of cardiovascular diseases. However, conflicting data exist on the specific role of TMAO in ischaemic stroke patients. We aimed to analyze the time course of TMAO levels in stroke patients compared with controls. METHODS In this prospective, case-control study, patients suffering from ischaemic stroke (onset <24 h) and control patients with less than two cardiovascular risk factors were enrolled. Plasma TMAO levels were analyzed on admission, after 48 h and after 3 months. The primary endpoint was the difference in TMAO levels on admission between stroke patients and controls. RESULTS A total of 196 patients with ischaemic stroke and 100 controls were included between February 2018 and April 2019. Plasma TMAO levels on admission were significantly higher in stroke patients than in controls [median value 4.09 (2.87-6.49) vs. 3.16 (2.08-5.16) µmol/L, P = 0.001]. There was a significant decrease in TMAO levels in stroke patients after 48 h [median at 48 h, 3.49 (2.30-5.39) µmol/L, P = 0.027]. TMAO levels increased again 3 months after stroke [median 4.23 (2.92-8.13) µmol/L, P = 0.047]. In controls, TMAO levels did not change between admission and after 48 h [median at 48 h, 3.14 (1.63-4.61) µmol/L, P = 0.11]. An inverse correlation between TMAO values and kidney function was found (Spearman rho -0.334, P < 0.001). CONCLUSIONS Our study emphasizes the importance of the time course of TMAO levels after ischaemic stroke. Future studies should define the time point of TMAO analysis, preferably in the acute phase (<24 h).
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Affiliation(s)
- C Schneider
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - J G Okun
- Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - K V Schwarz
- Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - J Hauke
- Dietmar-Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - M Zorn
- Central Laboratory, Department of Internal Medicine, University Hospital, Heidelberg, Germany
| | - C Nürnberg
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Ungerer
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - P A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - S Mundiyanapurath
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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6
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Ungerer MN, Ringleb P, Reuter B, Stock C, Ippen F, Hyrenbach S, Bruder I, Martus P, Gumbinger C, Schabet M, Schoser K, Daffertshofer M, Neumaier S, Sorge R, Drewitz E, Hyrenbach S. Stroke unit admission is associated with better outcome and lower mortality in patients with intracerebral hemorrhage. Eur J Neurol 2020; 27:825-832. [DOI: 10.1111/ene.14164] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 02/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- M. N. Ungerer
- Department of Neurology University Hospital Heidelberg Heidelberg
| | - P. Ringleb
- Department of Neurology University Hospital Heidelberg Heidelberg
| | | | - C. Stock
- Institute of Medical Biometry and Informatics (IMBI) University of Heidelberg Heidelberg
| | - F. Ippen
- Department of Neurology University Hospital Heidelberg Heidelberg
| | - S. Hyrenbach
- Qualitätssicherung im Gesundheitswesen Baden‐Wuerttemberg (GeQiK Baden‐Wuerttemberg) Stuttgart
| | - I. Bruder
- Qualitätssicherung im Gesundheitswesen Baden‐Wuerttemberg (GeQiK Baden‐Wuerttemberg) Stuttgart
| | - P Martus
- Institute for Clinical Epidemiology and Applied Biometry University of Tuebingen Tuebingen Germany
| | - C. Gumbinger
- Department of Neurology University Hospital Heidelberg Heidelberg
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7
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Berberich A, Schneider C, Herweh C, Hielscher T, Reiff T, Bendszus M, Gumbinger C, Ringleb P. Risk factors associated with progressive lacunar strokes and benefit from dual antiplatelet therapy. Eur J Neurol 2020; 27:817-824. [PMID: 31994783 DOI: 10.1111/ene.14159] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Early neurological deterioration (END) occurs in 20%-30% of patients with lacunar stroke and challenges their clinical management. This retrospective cohort study analyzed clinical and neuroimaging risk factors predicting the occurrence of END, the functional outcome after END and potential benefit from dual antiplatelet therapy (DAPT) in patients with lacunar strokes. METHODS Factors associated with END and benefit from DAPT were retrospectively analyzed in 308 patients with lacunar stroke symptoms and detected lacunar infarction by magnetic resonance imaging. END was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale (NIHSS) points, ≥2 NIHSS points for limb paresis or documented deterioration within 5 days after admission. Patients were treated with DAPT according to in-house standards. The primary efficacy end-point for functional outcome was fulfilled if NIHSS at discharge improved after END at least to the score at admission. RESULTS Male gender [odds ratio (OR) 2.08; 95% confidence interval (CI) 1.09-4.00], higher age (OR = 1.65 per 10 years; 95% CI 1.18-2.31), motor paresis (OR = 18.89, 95% CI 4.66-76.57) and infarction of the internal capsule or basal ganglia (OR = 3.58, 95% CI 1.26-10.14) were associated with an increased risk for END. A larger diameter of infarction (OR = 0.85, 95% CI 0.76-0.95), more microangiopathic lesions (OR = 0.75, 95% CI 0.57-0.99) and pontine localization (OR = 0.29, 95% CI 0.12-0.65) were factors associated with unfavorable functional outcome after END occurred. Localization in the internal capsule or basal ganglia was identified as a significant predictive factor for a benefit from DAPT after END. CONCLUSIONS Identified clinical and neuroimaging factors predicting END occurrence, functional outcome after END and potential benefit from DAPT might improve the clinical management of patients with lacunar strokes.
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Affiliation(s)
- A Berberich
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Schneider
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - T Hielscher
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - T Reiff
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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8
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Vollherbst DF, Herweh C, Schönenberger S, Seker F, Nagel S, Ringleb PA, Bendszus M, Möhlenbruch MA. The Influence of Angioarchitectural Features on the Success of Endovascular Embolization of Cranial Dural Arteriovenous Fistulas with Onyx. AJNR Am J Neuroradiol 2019; 40:2130-2136. [PMID: 31753837 DOI: 10.3174/ajnr.a6326] [Citation(s) in RCA: 6] [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: 07/24/2019] [Accepted: 09/26/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular embolization can be an effective treatment for cranial dural arteriovenous fistulas. However, a considerable number of dural arteriovenous fistulas still cannot be treated sufficiently. The purpose of this study was to report our single-center experience of endovascular embolization of dural arteriovenous fistulas with Onyx, including the investigation of the influence of angioarchitectural features on the treatment success. MATERIALS AND METHODS Clinical data, angioarchitectural features, complications, treatment success (defined as complete symptom remission for low-grade dural arteriovenous fistulas and complete occlusion for high-grade dural arteriovenous fistulas), and occlusion rates were assessed. The influence of various angioarchitectural features (including location, pattern of venous drainage, and quantity and origin of feeding arteries) was investigated using multivariable backward logistic regression. RESULTS One hundred four patients with 110 dural arteriovenous fistulas were treated in 132 treatment procedures. Treatment success and complete occlusion rates were 81.8% and 90.9%, respectively. After a mean follow-up of 23.6 months, 95.5% of the patients showed complete symptom remission or symptom relief. The overall complication rate was 8.3% (4.5% asymptomatic, 2.3% transient, and 1.5% permanent complications). Logistic regression showed that ≥10 feeding arteries (P = .041) and involvement of the ascending pharyngeal artery (P = .039) significantly lowered the probability of treatment success. Treatment success tended to be lower for low-grade dural arteriovenous fistulas, Cognard type I dural arteriovenous fistulas, and dural arteriovenous fistulas with involvement of dural branches of the internal carotid artery, however without reaching statistical significance in the multivariable model. CONCLUSIONS The presence of multiple feeding arteries and involvement of the pharyngeal artery negatively influence the treatment success of endovascular embolization of cranial dural arteriovenous fistulas with Onyx.
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Affiliation(s)
- D F Vollherbst
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
| | - C Herweh
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
| | - S Schönenberger
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - F Seker
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
| | - S Nagel
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
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9
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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Böckler D, Böhm M, Brückmann H, Debus ES, Fiehler J, Lang W, Mathias K, Ringelstein EB, Schmidli J, Stingele R, Zahn R, Zeller T, Hetzel A, Bodechtel U, Binder A, Glahn J, Hacke W, Ringleb PA. Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2. Int J Stroke 2019; 15:1747493019833017. [PMID: 30873912 PMCID: PMC7416333 DOI: 10.1177/1747493019833017] [Citation(s) in RCA: 30] [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: 07/22/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatment of individuals with asymptomatic carotid artery stenosis is still handled controversially. Recommendations for treatment of asymptomatic carotid stenosis with carotid endarterectomy (CEA) are based on trials having recruited patients more than 15 years ago. Registry data indicate that advances in best medical treatment (BMT) may lead to a markedly decreasing risk of stroke in asymptomatic carotid stenosis. The aim of the SPACE-2 trial (ISRCTN78592017) was to compare the stroke preventive effects of BMT alone with that of BMT in combination with CEA or carotid artery stenting (CAS), respectively, in patients with asymptomatic carotid artery stenosis of ≥70% European Carotid Surgery Trial (ECST) criteria. METHODS SPACE-2 is a randomized, controlled, multicenter, open study. A major secondary endpoint was the cumulative rate of any stroke (ischemic or hemorrhagic) or death from any cause within 30 days plus an ipsilateral ischemic stroke within one year of follow-up. Safety was assessed as the rate of any stroke and death from any cause within 30 days after CEA or CAS. Protocol changes had to be implemented. The results on the one-year period after treatment are reported. FINDINGS It was planned to enroll 3550 patients. Due to low recruitment, the enrollment of patients was stopped prematurely after randomization of 513 patients in 36 centers to CEA (n = 203), CAS (n = 197), or BMT (n = 113). The one-year rate of the major secondary endpoint did not significantly differ between groups (CEA 2.5%, CAS 3.0%, BMT 0.9%; p = 0.530) as well as rates of any stroke (CEA 3.9%, CAS 4.1%, BMT 0.9%; p = 0.256) and all-cause mortality (CEA 2.5%, CAS 1.0%, BMT 3.5%; p = 0.304). About half of all strokes occurred in the peri-interventional period. Higher albeit statistically non-significant rates of restenosis occurred in the stenting group (CEA 2.0% vs. CAS 5.6%; p = 0.068) without evidence of increased stroke rates. INTERPRETATION The low sample size of this prematurely stopped trial of 513 patients implies that its power is not sufficient to show that CEA or CAS is superior to a modern medical therapy (BMT) in the primary prevention of ischemic stroke in patients with an asymptomatic carotid stenosis up to one year after treatment. Also, no evidence for differences in safety between CAS and CEA during the first year after treatment could be derived. Follow-up will be performed up to five years. Data may be used for pooled analysis with ongoing trials.
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Affiliation(s)
- T Reiff
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
| | - HH Eckstein
- Department for Vascular and
Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - U Mansmann
- Institute of Medical Informatics,
Biometry and Epidemiology, Ludwig Maximilian University Munich, Munich,
Germany
| | - O Jansen
- Department of Radiology and
Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - G Fraedrich
- Department of Vascular Surgery,
University Hospital of Innsbruck, Innsbruck, Austria
| | - H Mudra
- Department of Internal Medicine,
Städtisches Klinikum München-Neuperlach, Munich, Germany
| | - D Böckler
- Department of Vascular Surgery,
University Hospital of Heidelberg, Heidelberg, Germany
| | - M Böhm
- Department of Internal Medicine,
University Hospital of Homburg/Saar, Homburg, Germany
| | - H Brückmann
- Department of Neuroradiology,
Ludwig-Maximilians-Universität, Munich, Germany
| | - ES Debus
- Department of Vascular Surgery,
University Hospital of Hamburg, Hamburg, Germany
| | - J Fiehler
- Department of Neuroradiology,
University Hospital of Hamburg, Hamburg, Germany
| | - W Lang
- Department of Vascular Surgery,
University Hospital Erlangen, Erlangen, Germany
| | - K Mathias
- Department of Radiology, Klinikum
Dortmund, Dortmund, Germany
| | - EB Ringelstein
- Department of Neurology,
University Hospital of Münster, Münster, Germany
| | - J Schmidli
- Department of Vascular Surgery,
University Hospital of Bern, Bern, Switzerland
| | - R Stingele
- Department of Neurology,
University of Kiel, Kiel, Germany
| | - R Zahn
- Department of Internal Medicine,
Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - T Zeller
- Department of Angiology,
University Hospital Freiburg, Bad Krozingen, Germany
| | - A Hetzel
- Department of Neurology,
University Hospital Freiburg, Freiburg, Germany
| | - U Bodechtel
- Department of Neurology,
University Hospital of Dresden, Dresden, Germany
| | - A Binder
- Department of Neurology, UKSH
Campus Kiel, Kiel, Germany
| | - J Glahn
- Department of Neurology, Johannes
Wesling Klinikum, Minden, Germany
| | - W Hacke
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
| | - PA Ringleb
- Department of Neurology, University
Hospital of Heidelberg, Heidelberg, Germany
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Seker F, Pfaff J, Schönenberger S, Herweh C, Nagel S, Ringleb PA, Bendszus M, Möhlenbruch MA. Clinical Outcome after Thrombectomy in Patients with Stroke with Premorbid Modified Rankin Scale Scores of 3 and 4: A Cohort Study with 136 Patients. AJNR Am J Neuroradiol 2018; 40:283-286. [PMID: 30573460 DOI: 10.3174/ajnr.a5920] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 11/07/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to analyze the clinical outcome after mechanical thrombectomy in patients with premorbid mRS 3 and 4 because there are currently no data on this patient group. MATERIALS AND METHODS Between January 2009 and November 2017, all patients with premorbid mRS 3 or 4 undergoing mechanical thrombectomy due to anterior circulation stroke were selected. Good outcome was defined as a clinical recovery to the status before stroke onset (ie, equal premorbid mRS and mRS at 90 days). In addition, mortality at discharge and at 90 days was analyzed. RESULTS One hundred thirty-six patients were included, of whom 81.6% presented with premorbid mRS 3; and 18.4%, with premorbid mRS 4; 24.0% of patients with premorbid mRS 4 achieved clinical recovery compared with 20.7% of patients with premorbid mRS 3 (P = .788). However, the proportion of hospital mortality and mortality at 90 days was nonsignificant, but markedly higher in patients with premorbid mRS 4. Multivariate analysis identified low NIHSS scores (OR, 0.92; 95% CI, 0.85-0.99; P = .040), high ASPECTS (OR, 1.45; 95% CI, 1.02-2.16; P = .049), and TICI 2b-3 (OR, 7.11; 95% CI, 1.73-49.90; P = .017) as independent predictors of good outcome. CONCLUSIONS Good outcome in patients with premorbid mRS 3 and 4 is less frequent compared with premorbid mRS 0-2. Nevertheless, about 20% of the patients return to their premorbid mRS, which may justify endovascular treatment. The most important predictor of good outcome is successful recanalization.
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Affiliation(s)
- F Seker
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
| | - J Pfaff
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
| | - S Schönenberger
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
| | - S Nagel
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
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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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Ringleb P, Steiner T, Knaup P, Hacke W, Haux R, Brigl B. An Integrated Approach for a Knowledge-based Clinical Workstation: Architecture and Experience. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1634492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Abstract:Today, the demand for medical decision support to improve the quality of patient care and to reduce costs in health services is generally recognized. Nevertheless, decision support is not yet established in daily routine within hospital information systems which often show a heterogeneous architecture but offer possibilities of interoperability. Currently, the integration of decision support functions into clinical workstations is the most promising way. Therefore, we first discuss aspects of integrating decision support into clinical workstations including clinical needs, integration of database and knowledge base, knowledge sharing and reuse and the role of standardized terminology. In addition, we draw up functional requirements to support the physician dealing with patient care, medical research and administrative tasks. As a consequence, we propose a general architecture of an integrated knowledge-based clinical workstation. Based on an example application we discuss our experiences concerning clinical applicability and relevance. We show that, although our approach promotes the integration of decision support into hospital information systems, the success of decision support depends above all on an adequate transformation of clinical needs.
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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 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, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Wakhloo A, Moonis M, Henninger N, Goddeau R, Massari F, Minaeian A, Lozano JD, Ramzan M, Stout C, Patel A, Majoie CB, Tunguturi A, Onteddu S, Carandang R, Howk M, Ribó M, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Dippel DW, Meler P, Huerga E, Gelabert S, Coscojuela P, Tomasello A, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Brown MM, Rovira A, Molina CA, Millán M, Muñoz L, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, Liebig T, García Bermejo P, Remollo S, Castaño C, García-Sort R, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Stijnen T, Dávalos A, Chamorro A, Urra X, Obach V, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Andersson T, Ariño H, Aceituno A, Rudilosso S, Renu A, Macho JM, San Roman L, Blasco J, López A, Macías N, Cardona P, Mattle H, Quesada H, Rubio F, Cano L, Lara B, de Miquel MA, Aja L, Serena J, Cobo E, Albers GW, Lees KR, Wahlgren N, Arenillas J, Roberts R, Minhas P, Al-Ajlan F, Salluzzi M, Zimmel L, Patel S, Eesa M, Martí-Fàbregas J, Jankowitz B, van der Heijden E, Serena J, Salvat-Plana M, López-Cancio E, Bracard S, Ducrocq X, Anxionnat R, Baillot PA, Barbier C, Derelle AL, Lacour JC, Ghannouti N, Richard S, Samson Y, Sourour N, Baronnet-Chauvet F, Clarencon F, Crozier S, Deltour S, Di Maria F, Le Bouc R, Leger A, Fleitour N, Mutlu G, Rosso C, Szatmary Z, Yger M, Zavanone C, Bakchine S, Pierot L, Caucheteux N, Estrade L, Kadziolka K, Hooijenga I, Leautaud A, Renkes C, Serre I, Desal H, Guillon B, Boutoleau-Bretonniere C, Daumas-Duport B, De Gaalon S, Derkinderen P, Evain S, Puppels C, Herisson F, Laplaud DA, Lebouvier T, Lintia-Gaultier A, Pouclet-Courtemanche H, Rouaud T, Rouaud Jaffrenou V, Schunck A, Sevin-Allouet M, Toulgoat F, Pellikaan W, Wiertlewski S, Gauvrit JY, Ronziere T, Cahagne V, Ferre JC, Pinel JF, Raoult H, Mas JL, Meder JF, Al Najjar-Carpentier AA, Geerling A, Birchenall J, Bodiguel E, Calvet D, Domigo V, Godon-Hardy S, Guiraud V, Lamy C, Majhadi L, Morin L, Naggara O, Lindl-Velema A, Trystram D, Turc G, Berge J, Sibon I, Menegon P, Barreau X, Rouanet F, Debruxelles S, Kazadi A, Renou P, van Vemde G, Fleury O, Pasco-Papon A, Dubas F, Caroff J, Godard Ducceschi S, Hamon MA, Lecluse A, Marc G, Giroud M, Ricolfi F, de Ridder A, Bejot Y, Chavent A, Gentil A, Kazemi A, Osseby GV, Voguet C, Mahagne MH, Sedat J, Chau Y, Suissa L, Greebe P, Lachaud S, Houdart E, Stapf C, Buffon Porcher F, Chabriat H, Guedin P, Herve D, Jouvent E, Mawet J, Saint-Maurice JP, de Bont-Stikkelbroeck J, Schneble HM, Turjman F, Nighoghossian N, Berhoune NN, Bouhour F, Cho TH, Derex L, Felix S, Gervais-Bernard H, Gory B, de Meris J, Manera L, Mechtouff L, Ritzenthaler T, Riva R, Salaris Silvio F, Tilikete C, Blanc R, Obadia M, Bartolini MB, Gueguen A, Janssen K, Piotin M, Pistocchi S, Redjem H, Drouineau J, Neau JP, Godeneche G, Lamy M, Marsac E, Velasco S, Clavelou P, Struijk W, Chabert E, Bourgois N, Cornut-Chauvinc C, Ferrier A, Gabrillargues J, Jean B, Marques AR, Vitello N, Detante O, Barbieux M, Licher S, Boubagra K, Favre Wiki I, Garambois K, Tahon F, Ashok V, Voguet C, Coskun O, Guedin P, Rodesch G, Lapergue B, Boodt N, Bourdain F, Evrard S, Graveleau P, Decroix JP, Wang A, Sellal F, Ahle G, Carelli G, Dugay MH, Gaultier C, Ros A, Lebedinsky AP, Lita L, Musacchio RM, Renglewicz-Destuynder C, Tournade A, Vuillemet F, Montoro FM, Mounayer C, Faugeras F, Gimenez L, Venema E, Labach C, Lautrette G, Denier C, Saliou G, Chassin O, Dussaule C, Melki E, Ozanne A, Puccinelli F, Sachet M, Slokkers I, Sarov M, Bonneville JF, Moulin T, Biondi A, De Bustos Medeiros E, Vuillier F, Courtheoux P, Viader F, Apoil-Brissard M, Bataille M, Ganpat RJ, Bonnet AL, Cogez J, Kazemi A, Touze E, Leclerc X, Leys D, Aggour M, Aguettaz P, Bodenant M, Cordonnier C, Mulder M, Deplanque D, Girot M, Henon H, Kalsoum E, Lucas C, Pruvo JP, Zuniga P, Bonafé A, Arquizan C, Costalat V, Saiedie N, Machi P, Mourand I, Riquelme C, Bounolleau P, Arteaga C, Faivre A, Bintner M, Tournebize P, Charlin C, Darcel F, Heshmatollah A, Gauthier-Lasalarie P, Jeremenko M, Mouton S, Zerlauth JB, Lamy C, Hervé D, Hassan H, Gaston A, Barral FG, Garnier P, Schipperen S, Beaujeux R, Wolff V, Herbreteau D, Debiais S, Murray A, Ford G, Muir KW, White P, Brown MM, Clifton A, Vinken S, Freeman J, Ford I, Markus H, Wardlaw J, Lees KR, Molyneux A, Robinson T, Lewis S, Norrie J, Robertson F, van Boxtel T, Perry R, Dixit A, Cloud G, Clifton A, Madigan J, Roffe C, Nayak S, Lobotesis K, Smith C, Herwadkar A, Koets J, Kandasamy N, Goddard T, Bamford J, Subramanian G, Lenthall R, Littleton E, Lamin S, Storey K, Ghatala R, Banaras A, Boers M, Aeron-Thomas J, Hazel B, Maguire H, Veraque E, Harrison L, Keshvara R, Cunningham J, 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, 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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Mundiyanapurath S, Hees K, Ahmed N, Wahlgren N, Uhlmann L, Kieser M, Ringleb PA, Hacke W, Nagel S. Predictors of symptomatic intracranial haemorrhage in off-label thrombolysis: an analysis of the Safe Implementation of Treatments in Stroke registry. Eur J Neurol 2017; 25:340-e11. [PMID: 29105904 DOI: 10.1111/ene.13507] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/20/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis (IVT) is the only approved pharmacological treatment for acute ischemic stroke. Off-label IVT for ischemic stroke is common. We aimed to analyse its safety in a large database. METHODS This was a retrospective analysis of the safe implementation of treatments in stroke (SITS) thrombolysis registry with regard to 11 off-label criteria according to the European licence for alteplase. Symptomatic intracranial haemorrhage (SICH) according to SITS was defined as primary safety endpoint and SICH according to the European Cooperative Acute Stroke Study (ECASS II) definition and the National Institute of Neurological Disorders and Stroke definition as secondary safety endpoints. Multivariable logistic regression analyses after replacing missing values using multiple imputations were performed. RESULTS Patients from 793 centres in 44 countries were included, mainly (95%) in Europe. A total of 56 258 patients who were treated with intravenous alteplase were included. Median age was 71 (IQR 61-78) years and median National Institutes of Health Stroke Scale score was 12 (IQR 7-17). A total of 16 740 (30%) patients received off-label IVT and 1037 (1.8%) patients suffered from SICH according to the SITS definition (SICH SITS). Median percentage of missing values per variable was 0.4%. The only two off-label criteria constituting independent positive and negative predictors for SICH SITS were high blood pressure (odds ratio, 1.39; 95% confidence interval, 1.08-1.80; P = 0.012) and minor stroke (odds ratio, 0.51; 95% confidence interval, 0.33-0.78; P = 0.002). Very severe stroke, previous stroke and diabetes, age and high glucose levels were additional independent predictors of SICH according to the ECASS II and National Institute of Neurological Disorders and Stroke definitions. CONCLUSIONS Thrombolysis appears to be safe with regard to SICH for most of the off-label criteria, especially for minor stroke, but is risky in patients with high blood pressure. Individual risk-benefit evaluation should be performed.
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Affiliation(s)
| | - K Hees
- Institute of Medical Biometry and Informatics, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - N Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm.,Department of Neurology, Karolinska University Hospital-Solna, Stockholm, Sweden
| | - N Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm.,Department of Neurology, Karolinska University Hospital-Solna, Stockholm, Sweden
| | - L Uhlmann
- Institute of Medical Biometry and Informatics, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - M Kieser
- Institute of Medical Biometry and Informatics, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg
| | - W Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg
| | - S Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg
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Messer M, Ringleb PA, Nagel S. Reply. AJNR Am J Neuroradiol 2017; 38:E86. [PMID: 28663261 PMCID: PMC7963614 DOI: 10.3174/ajnr.a5319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- M Messer
- Department of Neurology University Hospital Heidelberg Heidelberg, Germany
| | - P A Ringleb
- Department of Neurology University Hospital Heidelberg Heidelberg, Germany
| | - S Nagel
- Department of Neurology University Hospital Heidelberg Heidelberg, Germany
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Kumar R, Batchelder A, Saratzis A, AbuRahma A, Ringleb P, Lal B, Mas J, Steinbauer M, Naylor A. Restenosis after Carotid Interventions and Its Relationship with Recurrent Ipsilateral Stroke: A Systematic Review and Meta-analysis. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.05.003] [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: 11/29/2022]
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Pfaff J, Herweh C, Schieber S, Schönenberger S, Bösel J, Ringleb PA, Möhlenbruch M, Bendszus M, Nagel S. e-ASPECTS Correlates with and Is Predictive of Outcome after Mechanical Thrombectomy. AJNR Am J Neuroradiol 2017; 38:1594-1599. [PMID: 28596195 DOI: 10.3174/ajnr.a5236] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/22/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The e-ASPECTS software is a tool for the automated use of ASPECTS. Our aim was to analyze whether baseline e-ASPECT scores correlate with outcome after mechanical thrombectomy. MATERIALS AND METHODS Patients with ischemic strokes in the anterior circulation who were admitted between 2010 and 2015, diagnosed by CT, and received mechanical thrombectomy were included. The ASPECTS on baseline CT was scored by e-ASPECTS and 3 expert raters, and interclass correlation coefficients were calculated. The e-ASPECTS was correlated with functional outcome (modified Rankin Scale) at 3 months by using the Spearman rank correlation coefficient. Unfavorable outcome was defined as mRS 4-6 at 3 months, and a poor scan was defined as e-ASPECTS 0-5. RESULTS Two hundred twenty patients were included, and 147 (67%) were treated with bridging protocols. The median e-ASPECTS was 9 (interquartile range, 8-10). Intraclass correlation coefficients between e-ASPECTS and raters were 0.72, 0.74, and 0.76 (all, P < .001). e-ASPECTS (Spearman rank correlation coefficient = -0.15, P = .027) correlated with mRS at 3 months. Patients with unfavorable outcome had lower e-ASPECTS (median, 8; interquartile range, 7-10 versus median, 9; interquartile range, 8-10; P = .014). Sixteen patients (7.4%) had a poor scan, which was associated with unfavorable outcome (OR, 13.6; 95% CI, 1.8-104). Independent predictors of unfavorable outcome were e-ASPECTS (OR, 0.79; 95% CI, 0.63-0.99), blood sugar (OR, 1.01; 95% CI, 1.004-1.02), atrial fibrillation (OR, 2.64; 95% CI, 1.22-5.69), premorbid mRS (OR, 1.77; 95% CI, 1.21-2.58), NIHSS (OR, 1.11; 95% CI, 1.04-1.19), general anesthesia (OR, 0.24; 95% CI, 0.07-0.84), failed recanalization (OR, 8.47; 95% CI, 3.5-20.2), and symptomatic intracerebral hemorrhage (OR, 25.8; 95% CI, 2.5-268). CONCLUSIONS The e-ASPECTS correlated with mRS at 3 months and was predictive of unfavorable outcome after mechanical thrombectomy, but further studies in patients with poor scan are needed.
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Affiliation(s)
- J Pfaff
- From the Departments of Neuroradiology (J.P., C.H., M.M., M.B.)
| | - C Herweh
- From the Departments of Neuroradiology (J.P., C.H., M.M., M.B.)
| | - S Schieber
- Neurology (S. Shieber, S. Schönenberger, J.B., P.A.R., S.N.), University of Heidelberg, Heidelberg, Germany
| | - S Schönenberger
- Neurology (S. Shieber, S. Schönenberger, J.B., P.A.R., S.N.), University of Heidelberg, Heidelberg, Germany
| | - J Bösel
- Neurology (S. Shieber, S. Schönenberger, J.B., P.A.R., S.N.), University of Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S. Shieber, S. Schönenberger, J.B., P.A.R., S.N.), University of Heidelberg, Heidelberg, Germany
| | - M Möhlenbruch
- From the Departments of Neuroradiology (J.P., C.H., M.M., M.B.)
| | - M Bendszus
- From the Departments of Neuroradiology (J.P., C.H., M.M., M.B.)
| | - S Nagel
- Neurology (S. Shieber, S. Schönenberger, J.B., P.A.R., S.N.), University of Heidelberg, Heidelberg, Germany.
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Schönenberger S, Pfaff J, Uhlmann L, Klose C, Nagel S, Ringleb PA, Hacke W, Kieser M, Bendszus M, Möhlenbruch MA, Bösel J. The Impact of Conscious Sedation versus General Anesthesia for Stroke Thrombectomy on the Predictive Value of Collateral Status: A Post Hoc Analysis of the SIESTA Trial. AJNR Am J Neuroradiol 2017; 38:1580-1585. [PMID: 28596192 DOI: 10.3174/ajnr.a5243] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/17/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Radiologic selection criteria to identify patients likely to benefit from endovascular stroke treatment are still controversial. In this post hoc analysis of the recent randomized Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial, we aimed to investigate the impact of sedation mode (conscious sedation versus general anesthesia) on the predictive value of collateral status. MATERIALS AND METHODS Using imaging data from SIESTA, we assessed collateral status with the collateral score of Tan et al and graded it from absent to good collaterals (0-3). We examined the association of collateral status with 24-hour improvement of the NIHSS score, infarct volume, and mRS at 3 months according to the sedation regimen. RESULTS In a cohort of 104 patients, the NIHSS score improved significantly in patients with moderate or good collaterals (2-3) compared with patients with no or poor collaterals (0-1) (P = .011; mean, -5.8 ± 7.6 versus -1.1 ± 10.7). Tan 2-3 was also associated with significantly higher ASPECTS before endovascular stroke treatment (median, 9 versus 7; P < .001) and smaller mean infarct size after endovascular stroke treatment (median, 35.0 versus 107.4; P < .001). When we differentiated the population according to collateral status (0.1 versus 2.3), the sedation modes conscious sedation and general anesthesia were not associated with significant differences in the predictive value of collateral status regarding infarction size or functional outcome. CONCLUSIONS The sedation mode, conscious sedation or general anesthesia, did not influence the predictive value of collaterals in patients with large-vessel occlusion anterior circulation stroke undergoing thrombectomy in the SIESTA trial.
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Affiliation(s)
- S Schönenberger
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - J Pfaff
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - L Uhlmann
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - C Klose
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - S Nagel
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - P A Ringleb
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - W Hacke
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - M Kieser
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - M Bendszus
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - M A Möhlenbruch
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - J Bösel
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
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Messer MP, Schönenberger S, Möhlenbruch MA, Pfaff J, Herweh C, Ringleb PA, Nagel S. Minor Stroke Syndromes in Large-Vessel Occlusions: Mechanical Thrombectomy or Thrombolysis Only? AJNR Am J Neuroradiol 2017; 38:1177-1179. [PMID: 28408627 DOI: 10.3174/ajnr.a5164] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [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: 11/02/2016] [Accepted: 01/31/2017] [Indexed: 11/07/2022]
Abstract
While mechanical thrombectomy for large-vessel occlusions is now an evidence-based treatment, its efficacy and safety in minor stroke syndromes (NIHSS ≤ 5) is not proved. We identified, in our prospective data base, 378 patients with minor strokes in the anterior circulation; 54 (14.2%) of these had proved large-vessel occlusions. Eight of 54 (14.8%) were immediately treated with mechanical thrombectomy, 6/54 (11.1%) after early neurologic deterioration, and the rest were treated with standard thrombolysis only. Rates of successful recanalization were similar between the 2 mechanical thrombectomy groups (75% versus 100%). Rates of excellent outcome (modified Rankin Scale 0-1) were higher in patients with immediate thrombectomy (75%) compared with patients with delayed thrombectomy (33.3%) and thrombolysis only (55%). No symptomatic intracranial hemorrhage occurred in either group. These descriptive data are encouraging, and further analysis of large registries or even randomized controlled trials in this patient subgroup should be performed.
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Affiliation(s)
- M P Messer
- From the Departments of Neurology (M.P.M., S.S., P.A.R., S.N.)
| | - S Schönenberger
- From the Departments of Neurology (M.P.M., S.S., P.A.R., S.N.)
| | - M A Möhlenbruch
- Neuroradiology (M.A.M., J.P., C.H.), University of Heidelberg, Heidelberg, Germany
| | - J Pfaff
- Neuroradiology (M.A.M., J.P., C.H.), University of Heidelberg, Heidelberg, Germany
| | - C Herweh
- Neuroradiology (M.A.M., J.P., C.H.), University of Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- From the Departments of Neurology (M.P.M., S.S., P.A.R., S.N.)
| | - S Nagel
- From the Departments of Neurology (M.P.M., S.S., P.A.R., S.N.)
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20
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Seker F, Pfaff J, Wolf M, Ringleb PA, Nagel S, Schönenberger S, Herweh C, Möhlenbruch MA, Bendszus M, Pham M. Correlation of Thrombectomy Maneuver Count with Recanalization Success and Clinical Outcome in Patients with Ischemic Stroke. AJNR Am J Neuroradiol 2017; 38:1368-1371. [PMID: 28473346 DOI: 10.3174/ajnr.a5212] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/03/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In the treatment of acute thromboembolic stroke, the effectiveness and success of thrombus removal when using stent retrievers is variable. In this study, we analyzed the correlation of thrombectomy maneuver count with a good clinical outcome and recanalization success. MATERIALS AND METHODS One hundred and four patients with acute occlusion of the middle cerebral artery or the terminal internal carotid artery who were treated with thrombectomy were included in this retrospective study. A good clinical outcome was defined as a 90-day mRS of ≤2, and successful recanalization was defined as TICI 2b-3. RESULTS The maneuver count ranged between 1-10, with a median of 2. Multivariate logistic regression analyses identified an increasing number of thrombectomy maneuvers as an independent predictor of poor outcome (adjusted OR, 0.59; 95% CI, 0.38-0.87; P = .011) and unsuccessful recanalization (adjusted OR, 0.48; 95% CI, 0.32-0.66; P < .001). A good outcome was significantly more likely if finished within 2 maneuvers compared with 3 or 4 maneuvers, or even more than 4 maneuvers (P < .001). CONCLUSIONS An increasing maneuver count correlates strongly with a decreasing probability of both good outcome and recanalization. The probability of successful recanalization decreases below 50% if not achieved within 5 thrombectomy maneuvers. Patients who are recanalized within 2 maneuvers have the best chance of achieving a good clinical outcome.
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Affiliation(s)
- F Seker
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - J Pfaff
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Wolf
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - P A Ringleb
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Nagel
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Schönenberger
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Bendszus
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Pham
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.).,Department of Neuroradiology (M.P.), Würzburg University Hospital, Würzburg, Germany
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Möhlenbruch M, Pfaff J, Schönenberger S, Nagel S, Bösel J, Herweh C, Ringleb P, Bendszus M, Stampfl S. Endovascular Stroke Treatment of Nonagenarians. AJNR Am J Neuroradiol 2016; 38:299-303. [PMID: 27789451 DOI: 10.3174/ajnr.a4976] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/19/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although endovascular treatment has become a standard therapy in patients with acute stroke, the benefit for very old patients remains uncertain. The purpose of this study was the evaluation of procedural and outcome data of patients ≥90 years undergoing endovascular stroke treatment. MATERIALS AND METHODS We retrospectively analyzed prospectively collected data of patients ≥90 years in whom endovascular stroke treatment was performed between January 2011 and January 2016. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS, prestroke mRS), at discharge (NIHSS), and after 3 months (mRS). RESULTS Twenty-nine patients met the inclusion criteria for this analysis. The median prestroke mRS was 2. Successful recanalization (TICI ≥ 2b) was achieved in 22 patients (75.9%). In 9 patients, an NIHSS improvement ≥ 10 points was noted between admission and discharge. After 3 months, 17.2% of the patients had an mRS of 0-2 or exhibited prestroke mRS, and 24.1% achieved mRS 0-3. Mortality rate was 44.8%. There was only 1 minor procedure-related complication (small SAH without clinical sequelae). CONCLUSIONS Despite high mortality rates and only moderate overall outcome, 17.2% of the patients achieved mRS 0-2 or prestroke mRS, and no serious procedure-related complications occurred. Therefore, very high age should not per se be an exclusion criterion for endovascular stroke treatment.
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Affiliation(s)
- M Möhlenbruch
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - J Pfaff
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - S Schönenberger
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - S Nagel
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - J Bösel
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - P Ringleb
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - S Stampfl
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
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Eckstein HH, Reiff T, Ringleb P, Jansen O, Mansmann U, Hacke W. SPACE-2: A Missed Opportunity to Compare Carotid Endarterectomy, Carotid Stenting, and Best Medical Treatment in Patients with Asymptomatic Carotid Stenoses. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Pfaff J, Herweh C, Pham M, Schönenberger S, Nagel S, Ringleb PA, Bendszus M, Möhlenbruch M. Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Lower NIHSS Scores: Recanalization Rates, Periprocedural Complications, and Clinical Outcome. AJNR Am J Neuroradiol 2016; 37:2066-2071. [PMID: 27365324 DOI: 10.3174/ajnr.a4862] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/05/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy, in addition to intravenous thrombolysis, has become standard in acute ischemic stroke treatment in patients with large-vessel occlusion in the anterior circulation. However, previous randomized controlled stroke trials were not focused on patients with mild-to-moderate symptoms. Thus, there are limited data for patient selection, prediction of clinical outcome, and occurrence of complications in this patient population. The purpose of this analysis was to assess clinical and interventional data in patients treated with mechanical thrombectomy in case of ischemic stroke with mild-to-moderate symptoms. MATERIALS AND METHODS We performed a retrospective analysis of a prospectively collected stroke data base. Inclusion criteria were anterior circulation ischemic stroke treated with mechanical thrombectomy at our institution between September 2010 and October 2015 with an NIHSS score of ≤8. RESULTS Of 484 patients, we identified 33 (6.8%) with the following characteristics: median NIHSS = 5 (interquartile range, 4-7), median onset-to-groin puncture time = 320 minutes (interquartile range, 237-528 minutes). Recanalization (TICI = 2b-3) was achieved in 26 (78.7%) patients. Two cases of symptomatic intracranial hemorrhage were observed. Favorable (mRS 0-2) and moderate (mRS 0-3) clinical outcome at 90 days was achieved in 21 (63.6%) and 30 (90.9%) patients, respectively. CONCLUSIONS The clinical outcome of patients undergoing mechanical thrombectomy for acute ischemic stroke with mild stroke due to large-vessel occlusion appears to be predominately favorable, even in a prolonged time window. However, although infrequent, angiographic complications could impair clinical outcome. Future randomized controlled trials should assess the benefit compared with the best medical treatment.
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Affiliation(s)
- J Pfaff
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
| | - C Herweh
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
| | - M Pham
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
| | - S Schönenberger
- Neurology (S.S., S.N., P.A.R.), University of Heidelberg, Heidelberg, Germany
| | - S Nagel
- Neurology (S.S., S.N., P.A.R.), University of Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S.S., S.N., P.A.R.), University of Heidelberg, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
| | - M Möhlenbruch
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
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Eckstein HH, Reiff T, Ringleb P, Jansen O, Mansmann U, Hacke W. SPACE-2: A Missed Opportunity to Compare Carotid Endarterectomy, Carotid Stenting, and Best Medical Treatment in Patients with Asymptomatic Carotid Stenoses. Eur J Vasc Endovasc Surg 2016; 51:761-5. [PMID: 27085660 DOI: 10.1016/j.ejvs.2016.02.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/08/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Because of recent advances in best medical treatment (BMT), it is currently unclear whether any additional surgical or endovascular interventions confer additional benefit, in terms of preventing late ipsilateral carotid territory ischemic stroke in asymptomatic patients with significant carotid stenoses. The aim was to compare the stroke-preventive effects of BMT alone, with that of BMT in combination with carotid endarterectomy (CEA) or carotid artery stenting (CAS) in patients with high grade asymptomatic extracranial carotid artery stenosis. METHODS SPACE-2 was planned as a three-armed, randomized controlled trial (BMT alone vs. CEA plus BMT vs. CAS plus BMT, ISRCTN 78592017). However, because of slow patient recruitment, the three-arm study design was amended (July 2013) to become two parallel randomized studies (BMT alone vs. CEA plus BMT, and BMT alone vs. CAS plus BMT). RESULTS The change in study design did not lead to any significant increase in patient recruitment, and trial recruitment ceased after recruiting 513 patients over a 5 year period (CEA vs. BMT (n = 203); CAS vs. BMT (n = 197), and BMT alone (n = 113)). The 30 day rate of death/stroke was 1.97% for patients undergoing CEA, and 2.54% for patients undergoing CAS. No strokes or deaths occurred in the first 30 days after randomization in patients randomized to BMT. There were several potential reasons for the low recruitment rates into SPACE-2, including the ability for referring doctors to refer their patients directly for CEA or CAS outwith the trial, an inability to convince patients (who had come "mentally prepared" that an intervention was necessary) to accept BMT, and other economic constraints. CONCLUSIONS Because of slow recruitment rates, SPACE-2 had to be stopped after randomizing only 513 patients. The German Research Foundation will provide continued funding to enable follow up of all recruited patients, and it is also planned to include these data in any future meta-analysis prepared by the Carotid Stenosis Trialists Collaboration.
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Affiliation(s)
- H-H Eckstein
- Department of Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - T Reiff
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - O Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - U Mansmann
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig Maximilian University Munich, Munich, Germany
| | - W Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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Affiliation(s)
- P. Ringleb
- Neurologische Universitätsklinik Heidelberg
| | - G. Hamann
- Klinik für Neurologie und Neurologische Rehabilitation, Bezirkskrankenhaus Günzburg
| | - J. Röther
- Neurologische Abteilung, Asklepios Klinik Hamburg Altona
| | - O. Jansen
- Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Kiel
| | - C. Groden
- Abteilung für Neuroradiologie, Universitätsklinikum Mannheim
| | - R. Veltkamp
- Department of Stroke Medicine, Imperial College London
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Herweh C, Griebe M, Geisbüsch C, Szabo K, Neumaier-Probst E, Hennerici MG, Bendszus M, Ringleb PA, Nagel S. Frequency and temporal profile of recanalization after cerebral vein and sinus thrombosis. Eur J Neurol 2015; 23:681-7. [PMID: 26667584 DOI: 10.1111/ene.12901] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/01/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE The temporal course of recanalization and its association with clinical outcome were analysed in our patients with cerebral sinus and/or venous thrombosis (CSVT) and follow-up magnetic resonance imaging (MRI). METHODS Between January 1998 and September 2014 all patients from our institutions with CSVT were systematically analysed. Baseline data, treatment characteristics and follow-up MRI were retrospectively recorded. The status of recanalization was assessed as complete (CRec), partial (PRec) or failed recanalization. Clinical follow-up was measured with the modified Rankin Scale. Excellent outcome was defined as modified Rankin Scale 0-1. RESULTS Ninety-nine patients were identified; 97% of these patients were treated with oral anticoagulation (OAC) and the median (min-max) time of OAC was 7 months (1-84). CRec was achieved in 57.6% (57/99), PRec in 29.3% (29/99) and only 13 (13.1%) patients did not recanalize. The median (min-max) time to PRec was 4 months (0.25-14) and to CRec 6 months (2-34). Median time to last clinical follow-up was 8 months (1-88); 91.8% (89/99) had an excellent outcome at last clinical follow-up and only 2.1% (2/99) died. Only thrombosis of the superior sagittal sinus was independently associated with successful recanalization (odds ratio 16, 95% confidence interval 2-138). No severe haemorrhagic complications and no recurrence of CSVT occurred within clinical follow-up. No association of outcome and recanalization status was found. CONCLUSIONS The recanalization rate of CSVT under OAC was high and the median time to CRec was 6 months. Thrombosis of the superior sagittal sinus is a positive predictor of recanalization. Outcome in this cohort was excellent but no significant association of outcome and recanalization status was found.
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Affiliation(s)
- C Herweh
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - M Griebe
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - C Geisbüsch
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - K Szabo
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - E Neumaier-Probst
- Department of Neuroradiology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - M G Hennerici
- Department of Neurology, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - M Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - S Nagel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Pfaff J, Herweh C, Pham M, Schieber S, Ringleb PA, Bendszus M, Möhlenbruch M. Mechanical Thrombectomy of Distal Occlusions in the Anterior Cerebral Artery: Recanalization Rates, Periprocedural Complications, and Clinical Outcome. AJNR Am J Neuroradiol 2015; 37:673-8. [PMID: 26542233 DOI: 10.3174/ajnr.a4594] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/29/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Patients with acute ischemic stroke in the anterior circulation are at risk for either primary or, following mechanical thrombectomy, secondary occlusion of the anterior cerebral artery. Because previous studies had only a limited informative value, we report our data concerning the frequency and location of distal anterior cerebral artery occlusions, recanalization rates, periprocedural complications, and clinical outcome. MATERIALS AND METHODS We performed a retrospective analysis of prospectively collected data of patients with acute ischemic stroke undergoing mechanical thrombectomy in the anterior circulation between June 2010 and April 2015. RESULTS Of 368 patients included in this analysis, we identified 30 (8.1%) with either primary (n = 17, 4.6%) or secondary (n = 13, 3.5%) embolic occlusion of the distal anterior cerebral artery. The recanalization rate after placement of a stent retriever was 88%. Periprocedural complications were rare and included vasospasms (n = 3, 10%) and dissection (n = 1, 3.3%). However, 16 (53.5%) patients sustained an (at least partial) infarction of the anterior cerebral artery territory. Ninety days after the ictus, clinical outcome according to the modified Rankin Scale score was the following: 0-2, n = 11 (36.6%); 3-4, n = 9 (30%); 5-6, n = 10 (33.3%). CONCLUSIONS Occlusions of the distal anterior cerebral artery affect approximately 8% of patients with acute ischemic stroke in the anterior circulation receiving mechanical thrombectomy. Despite a high recanalization rate and a low complication rate, subsequent (partial) infarction in the anterior cerebral artery territory occurs in approximately half of patients. Fortunately, clinical outcome appears not to be predominately unfavorable.
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Affiliation(s)
- J Pfaff
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
| | - C Herweh
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
| | - M Pham
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
| | - S Schieber
- Neurology (S.S., P.A.R.), University of Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S.S., P.A.R.), University of Heidelberg, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
| | - M Möhlenbruch
- From the Departments of Neuroradiology (J.P., C.H., M.P., M.B., M.M.)
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Fisch U, von Felten S, Roubin G, Mali W, Jansen O, Howard G, Fraederich G, Chatellier G, Becquemin J, Algra A, Ringleb P, Mas J, Brown M, Brott T, Bonati L. Low Risk of Stroke or Death among Patients with Recently Symptomatic Carotid Stenosis Awaiting Revascularization—A Pooled Analysis of Recent Randomized Trials. J Neurol Surg A Cent Eur Neurosurg 2015. [DOI: 10.1055/s-0035-1564535] [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: 10/23/2022]
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Attigah N, Demirel S, Ringleb P, Hinz U, Hyhlik-Dürr A, Böckler D. Cross-flow determination by transcranial Doppler predicts clamping ischemia in patients undergoing carotid endarterectomy. J Cardiovasc Surg (Torino) 2015; 56:417-422. [PMID: 23867860] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
AIM Aim of the paper was to assess the reliability of preoperative cross-flow determination by transcranial Doppler measurement (TCD) to detect clamping ischemia in patients undergoing carotid endarterectomy with selective shunting. METHODS Retrospective one-to-one matched-pair analysis of 72 patients undergoing carotid endarterectomy with preoperative TCD scanning. Matching criteria were gender, degree of contralateral stenosis and the type of stenosis (asymptomatic or symptomatic). RESULTS Patients in need for a secondary shunt insertion had significantly less cross-flow in preoperative TCD measurement (N.=14; 38.89%) compared to the control group (N.=32; 88.89%: P=0.0001%). The sensitivity of the cross-flow determination to predict clamping ischemia was 88.9%, the specificity 61.1%. The risk of developing a clamping ischemia in the absence of a cross-flow was 12 fold higher (OR: 12.6; 95% CI: 3.7-43.3). The existence of circulatory impairment of the MCA was associated with the presence of a collateral flow in the ACoA (OR 3.21; P=0.0531; likelihood ratio test 0.0481). Other factors like renal insufficiency, the degree of stenosis or the stump pressure showed no association with a cross-flow of the ACoA in a multivariate model. CONCLUSION TCD scanning is highly reliable to detect cross-flow prior to carotid surgery and thus helpful to identify patients at risk for clamping ischemia and need for shunting.
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Affiliation(s)
- N Attigah
- Department of Vascular and Endovascular Surgery, University of Heidelberg, Heidelberg, Germany -
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Möhlenbruch MA, Herweh C, Jestaedt L, Stampfl S, Schönenberger S, Ringleb PA, Bendszus M, Pham M. The FRED flow-diverter stent for intracranial aneurysms: clinical study to assess safety and efficacy. AJNR Am J Neuroradiol 2015; 36:1155-61. [PMID: 25721079 DOI: 10.3174/ajnr.a4251] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/03/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow-diverter stents are emerging for the endovascular treatment of difficult-to-treat or otherwise untreatable cerebral aneurysms (wide-neck, fusiform, dissecting, blisterlike, or giant). We assessed the clinical safety and efficacy of the Flow-Redirection Endoluminal Device. MATERIALS AND METHODS This was an institutional review board-approved single-center observational clinical study in 29 patients with 34 aneurysms elected to be treated by endovascular intervention. After providing informed consent, patients were included according to the following criteria: aneurysm fundus-to-neck ratio <2 or neck diameter >4 mm, fusiform, dissecting, or giant aneurysms. The primary end point for clinical safety was the absence of death, absence of major or minor stroke, and absence of transient ischemic attack. The primary end point for treatment efficacy was complete angiographic occlusion according to the O'Kelly Marotta grading scale immediately after the procedure and at follow-up after 3 and 6 months (O'Kelly Marotta D: complete occlusion). RESULTS The Flow-Redirection Intraluminal Device deployment was technically successful in all cases. In 26/29 (89%) of patients, the primary end point of safety was reached; in the 3 remaining patients, 1 disabling ischemic stroke and 2 minor strokes with complete recovery at follow-up were observed. Angiographic (DSA and MRA) and clinical follow-up were available after 3 months in 29/29 (100%) and after 6 months in 25/29 (86%) patients (after 6 months, only MRA follow-up was performed according to our study protocol and institutional standard). At 3-month follow-up, complete occlusion was reached in 19/34 aneurysms (O'Kelly Marotta D: 19/34; 56%). At 6-month follow-up, aneurysm occlusion was complete in 22/30 aneurysms (O'Kelly Marotta D: 22/30; 73%). CONCLUSIONS Deployment of the Flow-Redirection Intraluminal Device flow-diverter stent is safe and effective in the treatment of difficult-to-treat or otherwise untreatable intracranial aneurysms.
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Affiliation(s)
- M A Möhlenbruch
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - C Herweh
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - L Jestaedt
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - S Stampfl
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - S Schönenberger
- Neurology (S. Schönenberger, P.A.R.); University of Heidelberg Medical Center, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S. Schönenberger, P.A.R.); University of Heidelberg Medical Center, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - M Pham
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
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Behrens L, Möhlenbruch M, Stampfl S, Ringleb PA, Hametner C, Kellert L, Pham M, Herweh C, Bendszus M, Rohde S. Effect of thrombus size on recanalization by bridging intravenous thrombolysis. Eur J Neurol 2014; 21:1406-10. [PMID: 25040586 DOI: 10.1111/ene.12509] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/26/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Thrombus length has been reported as an important predictor of successful recanalization by intravenous thrombolysis but its influence on bridging thrombolysis has not been investigated yet. The effect of thrombus length on recanalization rates evaluated by catheter angiography early after intravenous bridging thrombolysis was analyzed. METHODS Ninety-six consecutive patients with acute cerebral artery occlusion were included. Occlusion site and thrombus length on initial computed tomography angiography or magnetic resonance angiography were related to recanalization after intravenous bridging thrombolysis on the initial series of catheter angiography. RESULTS Eleven of 96 patients (11.5%) showed successful recanalization (TICI 2a, 2b or 3) after intravenous bridging thrombolysis. Mean thrombus length in these patients was 10.8 mm as opposed to 15.6 mm in patients without successful recanalization. No thrombus longer than 16 mm showed complete recanalization. Binary logistic regression demonstrated a significant influence of thrombus length on probability of recanalization (odds ratio 0.78, 95% confidence interval 0.65-0.95; P = 0.014). CONCLUSIONS Thrombus length is a significant predictor of recanalization rates after bridging thrombolysis. Overall recanalization rate within the time frame until interventional treatment is started was 11.5% after bridging thrombolysis.
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Affiliation(s)
- L Behrens
- Department of Neuroradiology, Heidelberg University, Heidelberg, Germany
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Wodarg F, Ringleb PA, Mali WP, Fraedrich G, Chatellier G, Becquemin JP, Brown MM, Algra A, Mas JL, Jansen O, Bonati LH. Einfluss von Stent Design und Protektionssystemen auf das Outcome der Stent-Angioplastie von Karotisstenosen – Ergebnisse der Carotid Stenting Trialists' Collaboration (CSTC). ROFO-FORTSCHR RONTG 2014. [DOI: 10.1055/s-0034-1373074] [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: 10/25/2022]
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Reiff T, Amiri H, Ringleb PA, Jansen O, Hacke W, Eckstein HH, Fraedrich G, Mudra H, Mansmann U. [Treatment of asymptomatic carotid artery stenosis: improvement of evidence with new SPACE-2 design necessary]. Nervenarzt 2013; 84:1504-7. [PMID: 24337619 DOI: 10.1007/s00115-013-3906-5] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Asymptomatic carotid artery stenosis may be treated with carotid endarterectomy (CEA), carotid artery stenting (CAS) or with best medical treatment (BMT) only. Definitive and evidence-based treatment recommendations for one of these options are currently not possible. Studies showing an advantage of CEA over BMT alone do not meet current standards from a pharmacological point of view. On the other hand, more recent data point to a further stroke risk reduction using BMT according to current standards. Studies on carotid artery stenting as a third alternative treatment are partially insufficient, especially when comparing CAS with BMT. Initiated in 2009, the randomized, controlled, multicenter SPACE-2 trial is intended to answer the question about the best treatment option of asymptomatic carotid artery stenosis; however, to increase recruitment rates as a condition for the successful completion of this important study, the trial design had to be modified.
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Möhlenbruch M, Stampfl S, Behrens L, Herweh C, Rohde S, Bendszus M, Hametner C, Nagel S, Ringleb PA, Pham M. Mechanical thrombectomy with stent retrievers in acute basilar artery occlusion. AJNR Am J Neuroradiol 2013; 35:959-64. [PMID: 24287087 DOI: 10.3174/ajnr.a3796] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Basilar artery occlusion remains one of the most devastating subtypes of ischemic stroke. The prognosis is poor if early recanalization is not achieved. The purpose of this study was to evaluate the safety and technical feasibility of self-expanding retrievable stents in the endovascular treatment of acute basilar artery occlusion. MATERIALS AND METHODS Twenty-four patients with acute basilar artery occlusion were treated with Solitaire FR or Revive SE devices between December 2009 and May 2012. Additional treatment included intravenous and/or intra-arterial thrombolysis (21/24) and percutaneous transluminal angioplasty/permanent stent placement (7/24). Recanalization was assessed by means of the TICI score. Clinical outcome was determined at discharge (NIHSS), and at 3 months (mRS). RESULTS Median NIHSS score on admission was 24; median duration of symptoms was 254 minutes. Successful recanalization (TICI 2b +3) by thrombectomy only was achieved in 18 patients (75%). Intracranial stent deployment after thrombectomy caused by underlying atherosclerotic stenosis was performed in 7 patients. If these patients with intracranial stent placement are included, successful recanalization was achieved in 21 of 24 patients (87.5%). NIHSS improvement ≥10 points was reached in 54% of patients (n = 13/24). Mortality during the first 3 months was 29% (7/24). After 3 months, 8 patients (33%) had a favorable clinical outcome (mRS 0-2). CONCLUSIONS In our series, application of self-expanding retrievable stents in acute basilar artery occlusion resulted in a high recanalization rate without procedural complications and good clinical outcome in one-third of patients.
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Affiliation(s)
- M Möhlenbruch
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - S Stampfl
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - L Behrens
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - C Herweh
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - S Rohde
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - M Bendszus
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - C Hametner
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)Neurology (C.H., S.N., P.A.R.), University of Heidelberg Medical Center, Heidelberg, Germany
| | - S Nagel
- Neurology (C.H., S.N., P.A.R.), University of Heidelberg Medical Center, Heidelberg, Germany
| | - P A Ringleb
- Neurology (C.H., S.N., P.A.R.), University of Heidelberg Medical Center, Heidelberg, Germany
| | - M Pham
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
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Kellert L, Schrader F, Ringleb P, Steiner T, Bösel J. The impact of low hemoglobin levels and transfusion on critical care patients with severe ischemic stroke: STroke: RelevAnt Impact of HemoGlobin, Hematocrit and Transfusion (STRAIGHT)--an observational study. J Crit Care 2013; 29:236-40. [PMID: 24332995 DOI: 10.1016/j.jcrc.2013.11.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 09/19/2013] [Accepted: 11/04/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE Optimal management of hemoglobin (Hb) and red blood cell transfusion (RBCT) in neurologic intensive care unit (NICU) patients has not been determined yet. Here we aimed to investigate the impact of anemia and transfusion activity in patients who had acute ischemic stroke. MATERIALS AND METHODS A retrospective analysis of clinical, laboratory, and outcome data of patients with severe acute ischemic stroke treated on our NICU between 2004 and 2011 was performed. RESULTS Of 109 patients, 97.2% developed anemia and 33% received RBCT. Significant correlations were found between NICU length of stay (NICU LOS) and lowest (nadir) Hb (correlation coefficient, -0.42, P < .001), Hb decrease (0.52, P < .001), nadir hematocrit (Hct; -0.43, P < .001), and Hct decrease (0.51, P < .001). Duration of mechanical ventilation (MV) was strongly associated with both nadir Hb (-0.41, P < .001) and decrease (0.42, P < .001) and nadir Hct (-0.43, P < .001) and decrease (0.40, P < .001). Red blood cell transfusion correlated with NICU LOS (0.33, P < .001) and with duration of MV (0.40, P < .001). None of these hematologic parameters correlated with in-hospital mortality or 90-day outcome. The linear regression model showed number of RBCT (0.29, P = .008), nadir Hb (-0.18, P = .049), Hb decrease (0.33, P < .001), nadir Hct (-0.18, P = .03), and Hct decrease (0.29, P < .001) to be independent predictors of NICU LOS. Duration of MV was also independently predicted by number of RBC transfusions (0.29, P < .001), nadir Hb (-0.20, P = .02), Hb decrease (0.25, P = .002), nadir Hct (-0.21, P = .015), and Hct decrease (0.26, P < .001). CONCLUSIONS Low and further decreasing Hb and Hct levels as well as RBCT activity are associated with prolonged NICU stay and duration of MV but not with mortality or long-term outcome. Our findings do not justify using a more aggressive transfusion practice at present.
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Affiliation(s)
- L Kellert
- Department of Neurology, University of Heidelberg, 69120 Heidelberg, Germany.
| | - F Schrader
- Department of Neurology, University of Heidelberg, 69120 Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, University of Heidelberg, 69120 Heidelberg, Germany
| | - T Steiner
- Department of Neurology, University of Heidelberg, 69120 Heidelberg, Germany; Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt am Main, Germany
| | - J Bösel
- Department of Neurology, University of Heidelberg, 69120 Heidelberg, Germany
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Reiff T, Ringleb PA. [Neurology and carotid artery interventions. What has to be done first?]. Herz 2013; 38:696-700. [PMID: 24170021 DOI: 10.1007/s00059-013-3963-3] [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] [Indexed: 11/24/2022]
Abstract
Optimum therapy for patients with carotid stenosis requires the interdisciplinary cooperation of surgeons, neurologists and angiologists. Important diagnostic methods are ultrasound sonography, contrast-enhanced computed tomography, magnetic resonance tomography and digital subtraction angiography. Treatment of carotid artery stenosis depends on whether the stenosis is symptomatic or asymptomatic. The treatment of choice (medical therapy only vs. carotid artery stenting vs. carotid endarterectomy) depends on the characteristics of the stenosis, the presence of cerebral lesions and the general physical condition of the patient. After the intervention continuous monitoring and treatment of vascular risk factors are mandatory.
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Affiliation(s)
- T Reiff
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland,
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Stampfl S, Ringleb PA, Möhlenbruch M, Hametner C, Herweh C, Pham M, Bösel J, Haehnel S, Bendszus M, Rohde S. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 2013; 35:741-6. [PMID: 24157733 DOI: 10.3174/ajnr.a3763] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE In past years, thrombectomy has become a widely used procedure in interventional neuroradiology for the treatment of acute intracranial occlusions. However, in 10-20% of patients, there are additional occlusions or stenotic lesions of the ipsilateral cervical internal carotid artery. The purpose of this study was to evaluate the feasibility of emergency carotid artery stent placement in combination with intracranial thrombectomy and the clinical outcome of the treated patients. MATERIALS AND METHODS We analyzed clinical and angiographic data of patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent-retriever devices in our institution between November 2009 and July 2012. Recanalization was assessed according to the Thrombolysis in Cerebral-Infarction score. Clinical outcome was evaluated at discharge (NIHSS) and after 3 months (mRS). RESULTS Overall, 24 patients were treated. The mean age was 67.2 years; mean occlusion time, 230.2 minutes. On admission, the median NIHSS score was 18. In all patients, the Thrombolysis in Cerebral Infarction score was zero before the procedure. Stent implantation was feasible in all cases. In 15 patients (62.5%), a Thrombolysis in Cerebral Infarction score ≥ 2b could be achieved. Six patients (25%) improved ≥10 NIHSS points between admission and discharge. After 90 days, the median mRS score was 3.0. Seven patients (29.2%) had a good clinical outcome (mRS 0-2), and 4 patients (16.6%) died, 1 due to fatal intracranial hemorrhage. Overall, symptomatic intracranial hemorrhage occurred in 4 patients (16.6%). CONCLUSIONS Emergency ICA stent implantation was technically feasible in all patients, and the intracranial recanalization Thrombolysis in Cerebral Infarction score of ≥2b was reached in a high number of patients. Clinical outcome and mortality seem to be acceptable for a cohort with severe stroke. However, a high rate of symptomatic intracranial hemorrhage occurred in our study.
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Affiliation(s)
- S Stampfl
- From the Departments of Neuroradiology (S.S., M.M., C. Herweh, M.P., S.H., M.B., S.R.)
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Nagel S, Kellert L, Möhlenbruch M, Bösel J, Rohde S, Ringleb P. Improved Clinical Outcome after Acute Basilar Artery Occlusion since the Introduction of Endovascular Thrombectomy Devices. Cerebrovasc Dis 2013; 36:394-400. [DOI: 10.1159/000356185] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 09/30/2013] [Indexed: 11/19/2022] Open
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Stampfl S, Ringleb PA, Haehnel S, Rocco A, Herweh C, Hametner C, Pham M, Moehlenbruch M, Bendszus M, Rohde S. Recanalization with stent-retriever devices in patients with wake-up stroke. AJNR Am J Neuroradiol 2012; 34:1040-3. [PMID: 23257610 DOI: 10.3174/ajnr.a3357] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Stent-retriever devices play an increasing role in the interventional treatment of acute stroke patients, because fast recanalization can be achieved. The purpose of this study was to evaluate the feasibility of stent-retriever recanalization in patients with wake-up stroke in the anterior circulation. MATERIALS AND METHODS We retrospectively analyzed clinical and angiographic data of 19 consecutive patients with wake-up stroke who were treated with stent-retriever devices between 2009 and October 2011. Recanalization was assessed by using the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 90 days by using the modified Rankin Scale. RESULTS Median NIHSS score at admission was 17 (IQR, 15-20). Before the procedure, the TICI score was 0 in 18 patients and 1 in 1 patient. Recanalization with stent-retriever devices was successful (TICI ≥ 2) in 94.7%. Mean time to flow restoration was 36.7 minutes and to complete recanalization 83.7 minutes. Symptomatic intracranial hemorrhage occurred in 4 patients (21.1%). Eight patients had an NIHSS improvement of ≥4 points between admission and discharge. After 90 days, 2 (10.5%) of our patients presented with mRS 0-2; seven (36.8%) died. CONCLUSIONS Despite successful and rapid recanalization with stent-retriever devices, good clinical outcome in patients with wake-up stroke is achieved in a minority of patients. Clinical outcome remains poor. Bleeding rates were higher compared with recanalization procedures within 6 hours after stroke onset.
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Affiliation(s)
- S Stampfl
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany.
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Kellert L, Herweh C, Sykora M, Gussmann P, Martin E, Ringleb PA, Steiner T, Bösel J. Loss of Penumbra by Impaired Oxygen Supply? Decreasing Hemoglobin Levels Predict Infarct Growth after Acute Ischemic Stroke: Stroke: Relevant Impact of Hemoglobin, Hematocrit and Transfusion (STRAIGHT) - An Observational Study. Cerebrovasc Dis Extra 2012; 2:99-107. [PMID: 23599701 PMCID: PMC3567874 DOI: 10.1159/000343731] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background The association of mortality and poor outcome with reduced levels of hemoglobin (Hb) and hematocrit (Hct) in patients admitted for ischemic stroke was recently demonstrated. The mechanisms behind this have remained unclear. Aims Here, we aimed to investigate a putative association between low Hb and Hct levels and infarct growth. Methods All consecutive patients who received intravenous thrombolysis based on multimodal magnetic resonance imaging during the years 1998–2009 were screened. Laboratory data as well as admission magnetic resonance images and follow-up computed tomography scans of 257 patients were assessed. Overall, data of 100 patients were of sufficient quality and further analyzed. Results Decrease in Hb and Hct as well as perfusion-weighted imaging volume, mismatch volume, and final infarct size on follow-up computed tomography were associated with infarct growth. A linear regression model revealed Hb decrease (β = 0.23, p = 0.02) to be a predictor of infarct growth, independent of mismatch volume (β = 0.27, p = 0.004) and minimum sodium (β = -0.21, p = 0.03), and adjusted to the non-predicting variables age, National Institute of Health Stroke Scale score, maximum leucocytes and C-reactive protein, blood glucose, and Hct decrease. Conclusion Hb levels that decrease after admission independently predict infarct growth in thrombolyzed stroke patients. The clinical implications of this relationship remain to be investigated.
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Affiliation(s)
- L Kellert
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Ringleb P, Görtler M, Nabavi D, Arning C, Sander D, Eckstein HH, Kühnl A, Berkefeld J, Diel R, Dörfler A, Kopp I, Langhoff R, Lawall H, Storck M. S3-Leitlinie Extracranielle Carotisstenose. Gefässchirurgie 2012. [DOI: 10.1007/s00772-012-1052-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rohde S, Seckinger J, Hähnel S, Ringleb PA, Bendszus M, Hartmann M. Stent design lowers angiographic but not clinical adverse events in stenting of symptomatic intracranial stenosis - results of a single center study with 100 consecutive patients. Int J Stroke 2012; 8:87-94. [PMID: 22296983 DOI: 10.1111/j.1747-4949.2011.00715.x] [Citation(s) in RCA: 16] [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] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Comparing safety and technical success of balloon-expandable stents and self-expanding stents for intracranial angioplasty and stenting in medically refractory intracranial atherosclerotic disease in a single center series. METHODS Fifty-four self-expanding stents and 46 balloon-expandable stents were implanted in 100 consecutive patients (mean age 64 years, 74% male) from April 2000 to September 2009. All patients had symptomatic intracranial stenosis (anterior circulation, n = 40; posterior circulation, n = 60), presenting with recurrent transient ischemic attack or stroke under antithrombotic treatment. Mean degree of stenosis before treatment was 83 ± 13%. We assessed safety, defined as any stroke or death during the procedure and at 30 days follow-up, and technical success, defined as accurate delivery of the stent at the site of the target lesion. RESULTS Safety - periprocedural stroke or hemorrhage occurred in 11 patients treated with balloon-expandable stent, and in 14 of the patients treated with a self-expanding stent. One patient with a balloon-expandable stent died because of acute vessel rupture during treatment. One balloon-expandable stent and one self-expanding stent patient developed a severe reperfusion hemorrhage that resulted in death. Overall, the combined stroke and death rate at 30-day follow-up was 25·0% (23·9% for balloon-expandable stent group and 25·9% for the self-expanding stent group, P = 0·84). Technical success - intracranial angioplasty and stenting was technically successful in 96·3% of the self-expanding stent and 89·1% of the balloon-expandable stent patients (P = 0·31). Vascular complications were significantly less frequent in patients treated with a self-expanding stent (11·1%) than with a balloon-expandable stent (36·9%, P = 0·002). CONCLUSION Despite a high technical success, the rate of clinical adverse events at 30 days after intracranial angioplasty and stenting is high independently of the stent design. Thus, further development of intracranial stent systems and careful patient selection are mandatory.
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Affiliation(s)
- S Rohde
- Department of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany.
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Gumbinger C, Krumsdorf U, Veltkamp R, Hacke W, Ringleb P. Continuous monitoring versus HOLTER ECG for detection of atrial fibrillation in patients with stroke. Eur J Neurol 2011; 19:253-7. [DOI: 10.1111/j.1468-1331.2011.03519.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Cerebral salt-wasting syndrome and the syndrome of inappropriate antidiuresis (SIAD) are the most important causes of non-iatrogenic hyponatraemia that can significantly complicate various brain diseases. Salt wasting without an underlying CNS disease may have been disregarded so far by clinicians and has been described as renal salt-wasting (RSW) in patients as drug side effect (eg, cisplatin), in older people with various common diseases (eg, hip fracture, pulmonary infections) and other sporadic conditions. In Guillain-Barré Syndrome (GBS), however, hyponatraemia has been described mainly as SIAD. However, symptoms of hyponatraemia rarely develop in GBS. Here, we report on a woman with GBS with dominant symptoms of dysautonomia and moderate severe hyponatraemia. We could identify RSW as part of the autonomic dysfunction that significantly contributed to disease worsening.
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Affiliation(s)
- T Lenhard
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany.
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Rizos T, Wagner A, Jenetzky E, Ringleb PA, Becker R, Hacke W, Veltkamp R. Paroxysmal atrial fibrillation is more prevalent than persistent atrial fibrillation in acute stroke and transient ischemic attack patients. Cerebrovasc Dis 2011; 32:276-82. [PMID: 21893980 DOI: 10.1159/000330348] [Citation(s) in RCA: 53] [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] [Received: 04/11/2011] [Accepted: 06/08/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cause of ischemic stroke and transient ischemic attack (TIA). More extensive diagnostic effort is required to detect paroxysmal AF (pxAF) than persistent AF (pAF); the prevalence of pxAF in stroke patients is unknown. We evaluated the prevalence of pAF and pxAF in ischemic stroke and TIA patients. METHODS Consecutive patients with acute ischemic stroke/TIA were enrolled prospectively. We aimed to detect patients with a history of AF, with AF newly diagnosed in the emergency room (ER), or with newly diagnosed AF during a 3-month period following the event. Differences in the frequency of AF diagnosis with respect to the disposition of patients after ER work-up were assessed. RESULTS A total of 692 patients were enrolled (male: 52.2%; ischemic stroke: 69.1%; TIA: 30.9%). A previously documented history of AF was present in 19.7% (pAF: 47.1%, pxAF: 52.9%). In 3.8% of patients, AF was newly diagnosed in the ER (pxAF: 61.5%) and in 5.2% during the 3-month follow-up period. The overall prevalence of AF was 28.6% (pxAF: 62.6%). Previously documented pxAF evaded diagnosis at ER presentation in 48.6%. The prevalence of AF increased with age (p < 0.001). Patients with pxAF were younger than those with pAF (p = 0.004) and more often female (p = 0.05). The presence of any AF was associated with higher initial NIHSS scores (p < 0.001) and higher modified Rankin scores after 3 months (p < 0.001). CONCLUSION pxAF occurs more often than pAF in stroke/TIA patients. As effective stroke prevention is available for AF, it is important to develop and evaluate sensitive methods for detecting pxAF.
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Affiliation(s)
- T Rizos
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Engelter ST, Soinne L, Ringleb P, Sarikaya H, Bordet R, Berrouschot J, Odier C, Arnold M, Ford GA, Pezzini A, Zini A, Rantanen K, Rocco A, Bonati LH, Kellert L, Strbian D, Stoll A, Meier N, Michel P, Baumgartner RW, Leys D, Tatlisumak T, Lyrer PA. IV thrombolysis and statins. Neurology 2011; 77:888-95. [DOI: 10.1212/wnl.0b013e31822c9135] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [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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Abstract
BACKGROUND The profile of patients with neurological diseases referred to specialized emergency rooms (ER) has not been reported and it is unknown whether a setting of decentralized ERs is associated with a high number of referrals because of inappropriate admissions. METHODS In this prospective study, consecutive patients of a specialized neurological ER were enrolled. Data encompassed time from symptom onset to admission, discharge diagnoses, data on hospitalization and on transfers to and from other ERs. RESULTS Thousand seven hundred and forty-three patients were enrolled. Most common diagnoses were cerebrovascular events (26.5%), headache disorders (13%) and seizures (12.7%). Time since onset of symptoms depended on who referred the patient (P<0.001); seizure patients presented earlier than other patients (P<0.001) and 30.5% of patients with cerebrovascular events presented within 3 h after symptom onset but did not present sooner than patients with other diagnoses. In 18%, diagnoses did not match neurological disorders, 4.5% of patients suffered from cardiovascular events. Referrals to and from other ERs rarely occurred (10.3% vs. 5.9%). Only 20 patients with acute cerebrovascular events were referred via other ERs (1.1%). CONCLUSION A system of a specialized neurological ER can quickly clear up uncertainties in interpreting neurological symptoms. Owing to the rising number of neurological patients in ERs, more studies are urgently needed comparing the different organizational forms for emergency services.
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Affiliation(s)
- T Rizos
- University of Heidelberg, Department of Neurology, Heidelberg, Germany.
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Stampfl S, Hartmann M, Ringleb PA, Haehnel S, Bendszus M, Rohde S. Stent placement for flow restoration in acute ischemic stroke: a single-center experience with the Solitaire stent system. AJNR Am J Neuroradiol 2011; 32:1245-8. [PMID: 21596812 DOI: 10.3174/ajnr.a2505] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE In acute thromboembolic stroke, mechanical recanalization with stents may result in immediate flow restoration. The Solitaire stent can be used both for flow restoration and thrombectomy. In this single-center experience, we report safety and efficacy data on the application of the Solitaire stent. MATERIALS AND METHODS Between March 2009 and July 2010, 18 patients were treated with the Solitaire stent. To evaluate perfusion of the occluded vessel segment before and after the intervention, the TICI score was used (0-3). Clinical outcome was assessed by using the mRS at discharge. RESULTS Overall, recanalization was successful in 16 of 18 patients (88.8%). There were no procedure-related complications. Mean TICI score after the intervention was 2.3 ± 0.8. In 5 patients, reocclusion of the treated vessel occurred immediately after retrieval of the temporarily opened stent, and permanent stent deployment was performed to maintain stable perfusion. In 3 patients, hemorrhage occurred after successful recanalization. Five patients died (infarction, n = 3; hemorrhage, n = 1; organ failure, n = 1). A good clinical outcome (mRS ≤2) was achieved in 33.3% of the patients, 5.5% had a moderate outcome (mRS, 3/4), and 61.2% had a poor outcome or died (mRS, 5/6). CONCLUSIONS Application of the Solitaire stent in acute stroke results in a high recanalization rate (88.8%) without procedural complications and with a good outcome in one-third of patients. These results encourage further evaluation of the stent in larger patient populations.
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Affiliation(s)
- S Stampfl
- Departments of Neuroradiology, University of Heidelberg, Heidelberg, Germany.
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