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Dhillon PS, do Nascimento VC, de Villiers L, Rice H. Endovascular Thrombectomy for Extensive Infarction (ASPECTS 0-2) in Acute Ischemic Stroke. Clin Neuroradiol 2024:10.1007/s00062-024-01408-0. [PMID: 38649450 DOI: 10.1007/s00062-024-01408-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia.
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.
| | | | - Laetitia de Villiers
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Hal Rice
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
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Dhillon PS, Singh N, Ospel JM, Roozenbeek B, Goyal M, Hill MD. Pre-Hospital Stroke Triage and Research: Challenges and Opportunities. Cerebrovasc Dis 2024:000538093. [PMID: 38527436 DOI: 10.1159/000538093] [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] [Received: 01/27/2024] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
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Carraro do Nascimento V, de Villiers L, Dhillon PS, Domitrovic L, Sesnan G, Leblanc JP, Ninnes L, Hughes I, Rice H. Transradial versus transfemoral access for diagnostic cerebral angiography: frequency of acute MRI findings in 500 consecutive patients at a single center. J Neurointerv Surg 2024:jnis-2024-021472. [PMID: 38503510 DOI: 10.1136/jnis-2024-021472] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/04/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND The frequency of clinically symptomatic and asymptomatic diffusion-weighted imaging (DWI) hyperintense lesions and their correlation with the transradial artery (TRA) approach is unclear. OBJECTIVE To assess the frequency of abnormal diffusion restriction foci on DWI following cerebral angiography (digital subtraction angiography (DSA)) with the TRA or transfemoral artery (TFA) approach and identify predictors of DWI restriction foci. METHODS We analysed data from consecutive diagnostic cerebral angiograms obtained between January 2021 and October 2023 at a single tertiary center. MRI DWI was performed 2 hours after DSA. Patients underwent neurological assessment periprocedurally, as well as prior to discharge. RESULTS 500 patients were analysed; 277 (55%) procedures were performed via TRA and 223 (45%) via TFA. Overall, 74 (14.8%) patients had abnormal findings in the postprocedure MRI DWI. A higher incidence of positive DWI findings was noted in the TRA group, with 46 (16.6%) patients, compared with 28 (12.6%) in the TFA group (P=0.21). Symptomatic events occurred in seven (2.5%) of the TRA group and in two (0.9%) of the TFA cohort (P=0.31). At 60 days, the neurological deficit rate was one (0.4%) for the TRA group and one (0.4%) for the TFA group. Procedure time was the only significant predictor of DWI restriction (OR=1.04 per minute; P=0.0001). CONCLUSION Although there were more symptomatic or asymptomatic embolic events with TRA than with the TFA approach following elective cerebral angiography, this was not significantly different. We recommend the choice of vascular access based on patient anatomy and characteristics, aimed at improving care through enhanced safety.
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Affiliation(s)
| | - Laetitia de Villiers
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Permesh Singh Dhillon
- Department of Interventional Neuroradiology, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Luis Domitrovic
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Genevieve Sesnan
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Jean-Philippe Leblanc
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Louise Ninnes
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Ian Hughes
- Office for Research Governance and Development, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Hal Rice
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Jung Y, Dhillon PS, Akarsu FG, Omar AT, Marotta TR, Spears J, Zafar A, Pereira VM, Diestro JDB. Balloon Guide Catheters: To Inflate or not to Inflate? World Neurosurg 2024; 183:255-256. [PMID: 38245484 DOI: 10.1016/j.wneu.2023.12.112] [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: 01/22/2024]
Affiliation(s)
- Youngkyung Jung
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Permesh Singh Dhillon
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Fatma Ger Akarsu
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Abdelsimar Tan Omar
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Thomas R Marotta
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Julian Spears
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada; Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Atif Zafar
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Vitor M Pereira
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Jose Danilo Bengzon Diestro
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada; Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada
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Marei O, Podlasek A, Soo E, Butt W, Gory B, Nguyen TN, Appleton JP, Richard S, Rice H, de Villiers L, Carraro do Nascimento V, Domitrovic L, McConachie N, Lenthall R, Nair S, Malik L, Panesar J, Krishnan K, Bhogal P, Dineen RA, England TJ, Campbell BCV, Dhillon PS. Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis. J Neurointerv Surg 2024:jnis-2023-021244. [PMID: 38253378 DOI: 10.1136/jnis-2023-021244] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Half of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic therapy (AAT) during EVT is safe and efficacious compared with standard therapy (ST) of EVT with or without prior intravenous thrombolysis. METHODS Electronic databases were searched (PubMed/MEDLINE, Embase, Cochrane Library) from 2010 until October 2023. Data were pooled using a random-effects model and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using ROBINS-I and ROB-2. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes were successful recanalization (modified Thrombolysis In Cerebral Infarction (TICI) 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS 41 randomized and non-randomized studies met the eligibility criteria. Overall, 15 316 patients were included; 3296 patients were treated with AAT during EVT and 12 020 were treated with ST alone. Compared with ST, patients treated with AAT demonstrated higher odds of functional independence (46.5% AAT vs 42.6% ST; OR 1.22, 95% CI 1.07 to 1.40, P=0.004, I2=48%) and a lower likelihood of 90-day mortality (OR 0.71, 95% CI 0.61 to 0.83, P<0.0001, I2=20%). The rates of sICH (OR 1.00, 95% CI 0.82 to 1.22,P=0.97, I2=13%) and successful recanalization (OR 1.09, 95% CI 0.84 to 1.42, P=0.52, I2=76%) were not significantly different. CONCLUSION The use of AAT during EVT may improve functional outcomes and reduce mortality rates compared with ST alone, without an increased risk of sICH. These findings should be interpreted with caution pending the results from ongoing phase III trials to establish the efficacy and safety of AAT during EVT.
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Affiliation(s)
- Omar Marei
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Anna Podlasek
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Emma Soo
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
- Radiology, Boston Medical Center Department of Radiology, Boston, Massachusetts, USA
| | - Jason P Appleton
- Stroke Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | | | - Hal Rice
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Laetitia de Villiers
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | | | - Luis Domitrovic
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Norman McConachie
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jasmin Panesar
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kailash Krishnan
- Stroke Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Robert A Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Bruce C V Campbell
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Permesh Singh Dhillon
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
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de Villiers L, Carraro do Nascimento V, Domitrovic L, Dhillon PS, Rice H. Vanguard Study: Initial experience with the new fourth generation Pipeline Vantage Flow Diverter (PVFD): 6-month results, technical and clinical considerations. J Neurointerv Surg 2024:jnis-2023-021182. [PMID: 38171607 DOI: 10.1136/jnis-2023-021182] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND The Pipeline Embolization Device has proven to be a safe and effective device for the treatment of intracranial aneurysms. The Pipeline Vantage Flow Diverter (PVFD) with Shield Technology is the new fourth generation of this implant, with modifications made compared to previous iterations. We aimed to evaluate the mechanical properties and clinical safety and efficacy of this device. METHODS Vanguard is a single arm, single center, prospective study. Between April 2021 and April 2023, all consecutive patients with an unruptured aneurysm treated with Pipeline Vantage flow-diverting stents were included. There were no aneurysm size or location exclusion criteria. Safety (neurological serious adverse events) and efficacy (device deployment and aneurysm occlusion) were independently reviewed. Imaging follow-up data, and immediate, early (<30 days), and delayed (>30 days) neurological serious adverse events were independently assessed. RESULTS 101 consecutive patients with a total of 115 aneurysms were included. The aneurysms were situated in the anterior (90.4%) or posterior (9.6%) circulations. A total of 124 devices were implanted. The deployment success rate was 100%. In four (4.0%) cases post-deployment angioplasty was required to optimize device wall apposition. Occlusion rates at 1 month were 54.7%, at 3 months 72.1%, and at 6 months 81.7%. Morbidity and mortality were 4.9% and 0%, respectively, at 6 months. Eight cases (6.9%) demonstrated in-stent stenosis, four of which had 'fish mouth' deformity. CONCLUSION Initial results of the new generation PVFD for unruptured intracranial aneurysm treatment demonstrate overall satisfactory device performance, safety profile, and effectiveness.
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Affiliation(s)
- Laetitia de Villiers
- Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | | | - Luis Domitrovic
- Interventional Neuroradiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Permesh Singh Dhillon
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Hal Rice
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
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Dhillon PS, De Villiers L, Carraro do Nascimento V, Domitrovic L, Campbell BCV, Rice H. Endovascular thrombectomy for large infarcts in acute ischemic stroke: does size still matter? J Neurointerv Surg 2023:jnis-2023-021188. [PMID: 38050182 DOI: 10.1136/jnis-2023-021188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Laetitia De Villiers
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | | | - Luis Domitrovic
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Hal Rice
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
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Carraro do Nascimento V, de Villiers L, Dhillon PS, Domitrovic L, Leblanc JP, Booth M, Rice H. The Aristotle 18 and 24 microwires in neuroIntervention: Early experience at a single centre. Interv Neuroradiol 2023:15910199231204923. [PMID: 37796767 DOI: 10.1177/15910199231204923] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Current neurointerventional procedures are expanding the use of large bore microcatheters, of up to 0.033" inner diameters, to accommodate intrasaccular flow disruptors or neck-bridging devices, including flow diverters. The use of large bore microwires may mitigate the ledge gap between wire and catheter, facilitate navigation and offer support in distal tortuous anatomy. We aim to report our early experience using the novel Aristotle (Scientia Vascular, West Valley City, UT) 18 and 24 microwires in neurovascular interventions. METHODS We analysed neurointerventional procedures in which the Aristotle 18 and 24 microwires were used at a single centre. Prospectively collected data, from March 2022 to February 2023, including patient's clinical outcome (successful target vessel, aneurysm catheterisation, peri-procedural complications (thromboembolic, haemorrhagic, vessel dissection or perforation) were analysed. RESULTS Overall, the use of Aristotle 18 and 24 microwires was recorded in 84 neurointerventional procedures during the study period, including endovascular aneurysm treatment (n = 30), endovascular thrombectomy (n = 46), dural venous sinus manometry/stent placement (n = 7), and extracranial carotid artery stent placement (n = 1). The Aristotle 18 microwire was used in conjunction with 0.021" microcatheters and the Aristotle 24 microwire with the 0.027 or 0.033" microcatheters. In all cases (100%), the target vessel or aneurysm was reached with the microwire, allowing seamless advancement of the selected microcatheters. No procedure related complications were recorded. CONCLUSIONS The use of the Aristotle 18 and 24 microwires in neurointerventional procedures is feasible and safe. The microwires provide reduced ledge gap, improved torquability, support and safety over standard 0.014" microwires.
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Affiliation(s)
| | - Laetitia de Villiers
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, QLD, Australia
| | - Permesh Singh Dhillon
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, QLD, Australia
| | - Luis Domitrovic
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, QLD, Australia
| | | | - Madison Booth
- Medical School, University of Queensland, St Lucia, QLD, Australia
| | - Hal Rice
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, QLD, Australia
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Monteiro A, Makalanda HLD, Wareham J, Jones J, Baig AA, Dhillon PS, Bhogal P, Mokin M, Brinjikji W, Siddiqui AH. Mechanical thrombectomy in medium vessel occlusions using the novel aspiration Q catheters: an international multicenter experience. J Neurointerv Surg 2023:jnis-2022-019619. [PMID: 37479480 DOI: 10.1136/jnis-2022-019619] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/24/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Medium vessel occlusions (MeVOs) comprise a large proportion of all stroke events. We performed a multicenter study of MIVI Q catheters, a novel design that optimizes suction forces without an increase in lumen diameter, for the treatment of MeVOs, aiming to evaluate its efficacy and safety. METHODS Databases of two US and two UK centers were retrospectively reviewed for MeVO patients (M2-M3, anterior cerebral artery (ACA), or posterior cerebral artery (PCA)) treated with Q catheters. Outcomes were assessed as successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2b), first pass effect (FPE), and modified FPE (mFPE) as single pass achieving mTICI ≥2c and mTICI≥2b, respectively, and 90 day modified Rankin Scale (mRS) score. RESULTS 69 patients were included (median age 71 years, IQR 56-82.5; 52.2% men). Median National Institutes of Health Stroke Scale (NIHSS) score at admission was 14, and Alberta Stroke Program Early CT Score (ASPECTS) was 9. Primary (without large vessel occlusion (LVO)) and secondary (with LVO) MeVOs represented 47.8% and 52.2% of cases, respectively. Q catheters used were Q3 (47.8%), Q4 (33.3%), Q5 (10.1%), and Q6 (8.7%). mTICI≥2b was achieved in 92.8% of patients, with FPE in 47.8%, and mFPE in 68.1%. Two (2.9%) intraprocedural complications (symptomatic intracranial hemorrhage) occurred. 50% (27/54) achieved an mRS score of ≤2 at the 90 day follow-up. The median NIHSS at admission was significantly higher in secondary than in primary MeVOs (19.5 vs 12, P=0.009). The rate of mRS ≤2 at 90 days was significantly higher in primary than in secondary MeVOs (77.3% vs 31.3%, P=0.002). CONCLUSIONS Treatment of MeVO patients with Q catheters resulted in optimal angiographic and clinical outcomes. Although angiographic results were similar between primary and secondary MeVOs, the former had less severe presenting NIHSS and better outcomes at 90 days than the latter.
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Affiliation(s)
- Andre Monteiro
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | | | - James Wareham
- North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Jesse Jones
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ammad A Baig
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Permesh Singh Dhillon
- Interventional Neuroradiology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Maxim Mokin
- Neurosurgery, Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | | | - Adnan H Siddiqui
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
- Neurosurgery and Radiology, Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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Dhillon PS, Butt W, Podlasek A, Bhogal P, McConachie N, Lenthall R, Nair S, Malik L, Lynch J, Goddard T, Barrett E, Krishnan K, Dineen RA, England TJ. Effect of proximal blood flow arrest during endovascular thrombectomy (ProFATE): Study protocol for a multicentre randomised controlled trial. Eur Stroke J 2023; 8:581-590. [PMID: 37231682 DOI: 10.1177/23969873231166194] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Observational studies have demonstrated improved outcomes with the adjunctive use of balloon guide catheters (BGC) during endovascular thrombectomy (EVT) for anterior circulation acute ischaemic stroke (AIS). However, the lack of high-level evidence and global practice heterogeneity justifies a randomised controlled trial (RCT) to investigate the effect of transient proximal blood flow arrest on the procedural and clinical outcomes of patients with AIS following EVT. HYPOTHESIS Proximal blood flow arrest in the cervical internal carotid artery during EVT for proximal large vessel occlusion is superior to no flow arrest in achieving complete vessel recanalisation. METHODS ProFATE is an investigator-initiated, pragmatic, multicentre RCT with blinding of participants and outcome assessment. An estimated 124 participants with an anterior circulation AIS due to large vessel occlusion, an NIHSS of ⩾2, ASPECTS ⩾ 5 and eligible for EVT using a first-line combined technique (contact aspiration and stent retriever) or contact aspiration only will be randomised (1:1) to receive BGC balloon inflation or no inflation during EVT. OUTCOMES The primary outcome is the proportion of patients achieving near-complete/complete vessel recanalisation (eTICI 2c-3) at the end of the EVT procedure. Secondary outcomes include the functional outcome (modified Rankin Scale at 90 days), new or distal vascular territory clot embolisation rate, near-complete/complete recanalisation after the first pass, symptomatic intracranial haemorrhage, procedure-related complications and death at 90 days. DISCUSSION This is the first RCT to investigate the effect of proximal blood flow arrest during EVT using a BGC on the procedural and clinical outcomes of patients with AIS due to large vessel occlusion.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jeremy Lynch
- Interventional Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Tony Goddard
- Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emma Barrett
- Department of Research and Innovation (Medical Statistics), Manchester University NHS Foundation Trust, Manchester, UK
- Centre for Biostatistics, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, Derby, UK
| | - Robert A Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, Derby, UK
- Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Ma A, Detaram HD, Steinfort B, Harrington T, Nguyen TN, Abdalkader M, Siopis G, Bath PM, Dhillon PS, Podlasek A, Qureshi AI, Qiu Z, Krishnan K. Antiplatelet Therapy in Neurointervention. Semin Neurol 2023; 43:466-479. [PMID: 37562452 DOI: 10.1055/s-0043-1771383] [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: 08/12/2023]
Abstract
The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.
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Affiliation(s)
- Alice Ma
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | | | - Brendan Steinfort
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Tim Harrington
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Centre, Boston, Massachusetts
| | | | - George Siopis
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Anna Podlasek
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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12
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Dhillon PS, Butt W, Podlasek A, McConachie N, Lenthall R, Nair S, Malik L, Bhogal P, Makalanda HLD, Spooner O, Krishnan K, Sprigg N, Mortimer A, Booth TC, Lobotesis K, White P, James MA, Bath P, Dineen RA, England TJ. Association between time to treatment and clinical outcomes in endovascular thrombectomy beyond 6 hours without advanced imaging selection. J Neurointerv Surg 2023; 15:336-342. [PMID: 35296526 DOI: 10.1136/neurintsurg-2021-018564] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/24/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The effectiveness and safety of endovascular thrombectomy (EVT) in the late window (6-24 hours) for acute ischemic stroke (AIS) patients selected without advanced imaging is undetermined. We aimed to assess clinical outcomes and the relationship with time-to-EVT treatment beyond 6 hours of stroke onset without advanced neuroimaging. METHODS Patients who underwent EVT selected with non-contrast CT/CT angiography (without CT perfusion or MR imaging), between October 2015 and March 2020, were included from a national stroke registry. Functional and safety outcomes were assessed in both early (<6 hours) and late windows with time analyzed as a continuous variable. RESULTS Among 3278 patients, 2610 (79.6%) and 668 (20.4%) patients were included in the early and late windows, respectively. In the late window, for every hour delay, there was no significant association with shift towards poorer functional outcome (modified Rankin Scale (mRS)) at discharge (adjusted common OR 0.98, 95% CI 0.94 to 1.01, p=0.27) or change in predicted functional independence (mRS ≤2) (24.5% to 23.3% from 6 to 24 hours; aOR 0.99, 95% CI0.94 to 1.04, p=0.85). In contrast, predicted functional independence was time sensitive in the early window: 5.2% reduction per-hour delay (49.4% to 23.5% from 1 to 6 hours, p=0.0001). There were similar rates of symptomatic intracranial hemorrhage (sICH) (3.4% vs 4.6%, p=0.54) and in-hospital mortality (12.9% vs 14.6%, p=0.33) in the early and late windows, respectively, without a significant association with time. CONCLUSION In this real-world study, there was minimal change in functional disability, sICH and in-hospital mortality within and across the late window. While confirmatory randomized trials are needed, these findings suggest that EVT remains feasible and safe when performed in AIS patients selected without advanced neuroimaging between 6-24 hours from stroke onset.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK .,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, The Royal London Hospital Barts Health NHS Trust, London, UK
| | | | - Oliver Spooner
- Stroke Medicine, The Royal London Hospital Barts Health NHS Trust, London, UK
| | - Kailash Krishnan
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alex Mortimer
- Interventional Neuroradiology, Southmead Hospital North Bristol NHS Trust, Bristol, Bristol, UK
| | - Thomas Calvert Booth
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, London, UK
| | - Philip White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Martin A James
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Philip Bath
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Robert A Dineen
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Mental Health and Clinical Neuroscience, School of Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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13
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Dhillon PS, Butt W, Marei O, Podlasek A, McConachie N, Lenthall R, Nair S, Malik L, Bhogal P, Makalanda HLD, Dineen RA, England TJ. Incidence and predictors of poor functional outcome despite complete recanalisation following endovascular thrombectomy for acute ischaemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107083. [PMID: 36931092 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107083] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Numerous ischaemic stroke patients experience poor functional outcome despite successful recanalisation following endovascular thrombectomy (EVT). We aimed to identify the incidence and predictors of futile complete recanalisation (FCR) in a national stroke registry. METHODS Patients who achieved complete recanalisation (mTICI 3) following EVT, between October 2015 and March 2020, were included from a United Kingdom national stroke registry. Modified Rankin Scale of 4-6 at discharge was defined as a 'poor/futile outcome'. Backward stepwise multivariable logistic regression analysis was performed with FCR as the dependent variable, incorporating all baseline characteristics, procedural time metrics and post-procedural events. RESULTS We included 2132 of 4383 patients (48.8%) with complete recanalisation post-EVT, of which 948 patients (44.4%) developed FCR. Following multivariable regression analysis adjusted for potential confounders, patients with FCR were associated with multiple baseline patient, imaging and procedural factors: age (p=0.0001), admission NIHSS scores (p=0.0001), pre-stroke disability (p=0.007), onset-to-puncture (p=0.0001) and procedural times (p=0.0001), presence of diabetes (p=0.005), and use of general anaesthesia (p=0.0001). Although not predictive of outcome, post-procedural events including development of any intracranial haemorrhage (ICH) (p=0.0001), symptomatic ICH (sICH) (p=0.0001) and early neurological deterioration (END) (p=0.007) were associated with FCR. CONCLUSION Nearly half of patients in this national registry experienced FCR following EVT. Significant predictors of FCR included increasing age, admission NIHSS scores, pre-stroke disability, onset-to-puncture and procedural times, presence of diabetes, atrial fibrillation, and use of general anaesthesia. Post procedural development of any ICH, sICH, and END were associated with FCR.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, UK; NIHR Nottingham Biomedical Research Centre, Nottingham, UK; Radiological Sciences, Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, UK.
| | - Waleed Butt
- Interventional Neuroradiology, University Hospitals Birmingham NHS Trust, UK
| | - Omar Marei
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, UK; Radiological Sciences, Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, UK
| | - Anna Podlasek
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, UK
| | - Norman McConachie
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, UK
| | - Sujit Nair
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, UK
| | - Luqman Malik
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Robert A Dineen
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK; Radiological Sciences, Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, UK; Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, UK
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14
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Dhillon PS, White P, Goyal M, van Zwam WH, Lenthall R. Perfusion imaging in acute ischaemic stroke - the beginning of the end? Clin Med (Lond) 2023; 23:185-186. [PMID: 36958844 PMCID: PMC11046506 DOI: 10.7861/clinmed.2022-0554] [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] [Indexed: 03/25/2023]
Abstract
Endovascular thrombectomy (EVT) for large vessel occlusion in acute ischaemic stroke is the standard of care when initiated within 6 hours of stroke onset, and is performed between 6-24 hours using advanced neuroimaging (CT perfusion or MR imaging) for patients who meet the strict imaging selection criteria. However, adherence to the restrictive imaging criteria recommended by current guidelines is impeded in many parts of the world, including the UK, by resource constraints and limited access to advanced neuroimaging in the emergency setting. Furthermore, recent randomised and non-randomised studies have demonstrated that patients selected without advanced neuroimaging (with non-contrast CT and CT angiography only) using less restrictive imaging criteria for EVT eligibility beyond 6 hours from onset still benefited from EVT treatment, thereby increasing the proportion of patients eligible for EVT and widening the potential treatment impact at a population level. Hence, current guidelines should be updated expeditiously to reflect the level I evidence in support of more liberal imaging selection criteria for patients presenting with acute ischaemic stroke due to a large vessel occlusion.
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Affiliation(s)
| | - Phil White
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Wim H van Zwam
- Maastricht University Medical Center, Maastricht, the Netherlands
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15
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Dhillon PS, Butt W, Podlasek A, Barrett E, McConachie N, Lenthall R, Nair S, Malik L, James MA, Dineen RA, England TJ. Endovascular thrombectomy beyond 24 hours from ischemic stroke onset: a propensity score matched cohort study. J Neurointerv Surg 2023; 15:233-237. [PMID: 35169031 DOI: 10.1136/neurintsurg-2021-018591] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/30/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The safety and functional outcome of endovascular thrombectomy (EVT) in the very late (VL; >24 hours) time window from ischemic stroke onset remains undetermined. METHODS Using data from a national stroke registry, we used propensity score matched (PSM) individual level data of patients who underwent EVT, selected with CT perfusion or non-contrast CT/CT angiography, between October 2015 and March 2020. Functional and safety outcomes were assessed in both late (6-24 hours) and VL time windows. Subgroup analysis was performed of imaging selection modality in the VL time window. RESULTS We included 1150 patients (late window: 1046 (208 after PSM); VL window: 104 (104 after PSM)). Compared with EVT treatment initiation between 6 and 24 hours, patients treated in the VL window had similar modified Rankin Scale (mRS) scores at discharge (ordinal shift; common OR=1.08, 95% CI 0.69 to 1.47, p=0.70). No significant differences in achieving good functional outcome (mRS ≤2 at discharge; 28.8% (VL) vs 29.3% (late), OR=0.97, 95% CI 0.58 to 1.64, p=0.93), successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b-3) (p=0.77), or safety outcomes of symptomatic intracranial hemorrhage (p=0.43) and inhospital mortality (p=0.23) were demonstrated. In the VL window, there was no significant difference in functional outcome among patients selected with perfusion versus those selected without perfusion imaging (common OR=1.38, 95% CI 0.81 to 1.76, p=0.18). CONCLUSION In this real world study, EVT beyond 24 hours from stroke onset or last known well appeared to be feasible, with comparable safety and functional outcomes to EVT initiation between 6 and 24 hours. Randomized trials assessing the efficacy of EVT in the VL window are warranted, but may only be feasible with a large international collaborative approach.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK .,NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Emma Barrett
- Department of Research and Innovation (Medical Statistics), Manchester University NHS Foundation Trust, Manchester, UK.,Centre for Biostatistics, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin A James
- Exeter Medical School, University of Exeter, Exeter, UK.,Stroke, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Robert A Dineen
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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16
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Dhillon PS, Butt W, Podlasek A, McConachie N, Lenthall R, Nair S, Malik L, Booth TC, Bhogal P, Makalanda HLD, Spooner O, Mortimer A, Lamin S, Chavda S, Chew HS, Nader K, Al-Ali S, Butler B, Rajapakse D, Appleton JP, Krishnan K, Sprigg N, Smith A, Lobotesis K, White P, James MA, Bath PM, Dineen RA, England TJ. Perfusion Imaging for Endovascular Thrombectomy in Acute Ischemic Stroke Is Associated With Improved Functional Outcomes in the Early and Late Time Windows. Stroke 2022; 53:2770-2778. [PMID: 35506384 PMCID: PMC9389941 DOI: 10.1161/strokeaha.121.038010] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 11/16/2022]
Abstract
The impact on clinical outcomes of patient selection using perfusion imaging for endovascular thrombectomy (EVT) in patients with acute ischemic stroke presenting beyond 6 hours from onset remains undetermined in routine clinical practice.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.).,National Institute for Health and Care Research Nottingham Biomedical Research Centre, University of Nottingham, United Kingdom. (P.S.D., A.P., R.A.D.)
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Anna Podlasek
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, University of Nottingham, United Kingdom. (P.S.D., A.P., R.A.D.)
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.)
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.)
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.)
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.)
| | - Thomas C Booth
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, United Kingdom (T.C.B.).,School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (T.C.B.)
| | - Pervinder Bhogal
- Interventional Neuroradiology, The Royal London Hospital, Barts Health NHS Trust, United Kingdom. (P.B., H.L.D.M.)
| | | | - Oliver Spooner
- Stroke, The Royal London Hospital, Barts Health NHS Trust, United Kingdom. (O.S.)
| | - Alex Mortimer
- Interventional Neuroradiology, Southmead Hospital, North Bristol NHS Trust, United Kingdom (A.M.)
| | - Saleh Lamin
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Swarupsinh Chavda
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Han Seng Chew
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Kurdow Nader
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Samer Al-Ali
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Benjamin Butler
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Dilina Rajapakse
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Jason P Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, United Kingdom (J.P.A.).,Institute of Applied Health Research, College of Dental and Medical Sciences, University of Birmingham, United Kingdom (J.P.A.)
| | - Kailash Krishnan
- Stroke, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (K.K., N.S., P.M.B.)
| | - Nikola Sprigg
- Stroke, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (K.K., N.S., P.M.B.).,Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom. (N.S., P.M.B., T.J.E.)
| | - Aubrey Smith
- Interventional Neuroradiology, Hull Royal Infirmary, Hull and East Yorkshire Hospitals NHS Trust, United Kingdom (A.S.)
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (K.L.)
| | - Phil White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom (P.W.)
| | - Martin A James
- University of Exeter Medical School, United Kingdom (M.A.J.).,Royal Devon and Exeter NHS Foundation Trust, United Kingdom (M.A.J.).,Sentinel Stroke National Audit Programme, King's College London, United Kingdom (M.A.J.)
| | - Philip M Bath
- Stroke, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (K.K., N.S., P.M.B.).,Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom. (N.S., P.M.B., T.J.E.)
| | - Robert A Dineen
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, University of Nottingham, United Kingdom. (P.S.D., A.P., R.A.D.).,Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom. (R.A.D.)
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom. (N.S., P.M.B., T.J.E.).,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, United Kingdom (T.J.E.)
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17
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Dhillon PS, Butt W, Podlasek A, McConachie N, Lenthall R, Nair S, Malik L, Hewson DW, Bhogal P, Makalanda HLD, James MA, Dineen RA, England TJ. Association between anesthesia modality and clinical outcomes following endovascular stroke treatment in the extended time window. J Neurointerv Surg 2022; 15:478-482. [PMID: 35450928 DOI: 10.1136/neurintsurg-2022-018846] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/08/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is a paucity of data on anesthesia-related outcomes for endovascular treatment (EVT) in the extended window (>6 hours from ischemic stroke onset). We compared functional and safety outcomes between local anesthesia (LA) without sedation, conscious sedation (CS) and general anesthesia (GA). METHODS Patients who underwent EVT in the early (<6 hours) and extended time windows using LA, CS, or GA between October 2015 and March 2020 were included from a UK national stroke registry. Multivariable analyses were performed, adjusted for age, sex, baseline stroke severity, pre-stroke disability, EVT technique, center, procedural time and IV thrombolysis. RESULTS A total of 4337 patients were included, 3193 in the early window (1135 LA, 446 CS, 1612 GA) and 1144 in the extended window (357 LA, 134 CS, 653 GA). Compared with GA, patients treated under LA alone had increased odds of an improved modified Rankin Scale (mRS) score at discharge (early: adjusted common (ac) OR=1.50, 95% CI 1.29 to 1.74, p=0.001; extended: acOR=1.29, 95% CI 1.01 to 1.66, p=0.043). Similar mRS scores at discharge were found in the LA and CS cohorts in the early and extended windows (p=0.21). Compared with CS, use of GA was associated with a worse mRS score at discharge in the early window (acOR=0.73, 95% CI 0.45 to 0.96, p=0.017) but not in the extended window (p=0.55). There were no significant differences in the rates of symptomatic intracranial hemorrhage or in-hospital mortality across the anesthesia modalities in the extended window. CONCLUSION LA without sedation during EVT was associated with improved functional outcomes compared with GA, but not CS, within and beyond 6 hours from stroke onset. Prospective studies assessing anesthesia-related outcomes in the extended time window are warranted.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK .,NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham School of Medicine, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Norman McConachie
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David W Hewson
- Anaesthesia and Critical Care Research Group, Academic Unit of Injury Inflammation and Recovery Sciences, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Martin A James
- Exeter Medical School, University of Exeter Medical School, Exeter, UK.,Stroke, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Robert A Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham School of Medicine, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Nottingham, UK
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18
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Strømsnes TA, Kaugerud Hagen TJ, Ouyang M, Wang X, Chen C, Rygg SE, Hewson D, Lenthall R, McConachie N, Izzath W, Bath PM, Dhillon PS, Podlasek A, England T, Sprigg N, Robinson TG, Advani R, Ihle-Hansen H, Sandset EC, Krishnan K. Pressor therapy in acute ischaemic stroke: an updated systematic review. Eur Stroke J 2022; 7:99-116. [PMID: 35647316 PMCID: PMC9134777 DOI: 10.1177/23969873221078136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/17/2022] [Indexed: 11/15/2022] Open
Abstract
Background Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS. Methods We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS. Results We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken. Conclusion Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.
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Affiliation(s)
- Torbjørn Austveg Strømsnes
- Department of Neurosurgery, Oslo University hospital, Norway
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Truls Jørgen Kaugerud Hagen
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Geriatric Medicine, Oslo University hospital, Norway
| | - Menglu Ouyang
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
| | - Xia Wang
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
| | - Chen Chen
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
- The George Institute for Global Health, Peking University Health Science Center, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Silje-Emilie Rygg
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Geriatric Medicine, Oslo University hospital, Norway
| | - David Hewson
- Department of Anaesthesia, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rob Lenthall
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Norman McConachie
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Wazim Izzath
- Department of Neuroradiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Philip M Bath
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| | - Permesh Singh Dhillon
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Anna Podlasek
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy England
- Department of Stroke Medicine, Royal Derby Hospital, Derby, UK
| | - Nikola Sprigg
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| | - Thompson G Robinson
- College of Life Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Rajiv Advani
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
| | - Hege Ihle-Hansen
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
| | - Else Charlotte Sandset
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Norwegian Air Ambulance Foundation, Norway
| | - Kailash Krishnan
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
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19
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Podlasek A, Dhillon PS, Butt W, Grunwald IQ, England TJ. To bridge or not to bridge: summary of the new evidence in endovascular stroke treatment. Stroke Vasc Neurol 2022; 7:179-181. [PMID: 35105731 PMCID: PMC9240584 DOI: 10.1136/svn-2021-001465] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK .,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Permesh Singh Dhillon
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Interventional Neuroradiology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Iris Q Grunwald
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Timothy J England
- Stroke, Division of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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20
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Malik L, Butt W, Dhillon PS, Lenthall R. Isolated clival subdural haemorrhage from a dolicoectactic vertebrobasilar aneurysm: Case report and overview of endovascular treatment strategies. J Cerebrovasc Endovasc Neurosurg 2021; 23:365-371. [PMID: 34963259 PMCID: PMC8743819 DOI: 10.7461/jcen.2021.e2020.12.004] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 07/17/2021] [Indexed: 11/23/2022] Open
Abstract
Posterior fossa aneurysms presenting with isolated subdural haemorrhage (SDH) have scarcely been described with no cases attributed to a vertebrobasilar (VB) location. Non-saccular VB aneurysms are a distinct sub-group and in this report we also discuss the pathophysiology and treatment options for these difficult-to-manage lesions. We present a case of a 49 year-old man who presented with a 7-day history of severe headaches who was found to have an isolated acute clival SDH. Vascular imaging revealed a VB dolicoectatic segment with superimposed fusiform dilatations that contacted the dura adjacent to the SDH. A staged treatment was performed with initial parental vessel occlusion of the ruptured vertebral artery segment and subsequent insertion of a braided stent (LEO) with flow diverting properties into the progressively dilating basilar artery. A third procedure was performed to occlude a recurrent pouch at the lower basilar dilatation. Complete angiographic occlusion was achieved and the patient is under continued surveillance. To our knowledge, this is the first case of a ruptured non-saccular VB aneurysm presenting with radiologically isolated clival SDH. Clinical history will often inform the need for vascular imaging in such atypical presentations. Managing these lesions remains an endovascular challenge and requires a specialist multi-disciplinary approach.
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Affiliation(s)
- Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Waleed Butt
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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21
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Butt W, Dhillon PS, Lenthall R, Malik L, Izzath W, Krishnan K, George B, Pointon K. Left Atrial Enlargement on Non-Gated CT Is Associated with Large Vessel Occlusion in Acute Ischaemic Stroke. Cerebrovasc Dis Extra 2021; 11:87-91. [PMID: 34551410 PMCID: PMC8543283 DOI: 10.1159/000519121] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Recent reports have suggested that atrial fibrillation (AF) is more prevalent in the large vessel occlusion (LVO) subgroup of acute ischaemic stroke patients. Given the association between left atrial enlargement (LAE) and AF, we sought to evaluate the feasibility of assessing LAE on non-gated CT and its association with LVO in the hyperacute stroke setting. Methods We analysed our prospectively collected database that included all stroke patients referred for consideration of endovascular treatment between April 14, 2020, and May 21, 2020. During this period, a CT chest was included in our regional stroke protocol to aid triage of patients suspected for COVID-19 from which cardiac measurements were obtained. Patients were dichotomized into LVO and no-LVO groups, and LA measurements were trichotomized into normal, borderline, and enlarged. Univariate analyses were performed between groups. Results Of the included 38 patients, 21 were categorized as LVO and 17 as no LVO. There was a statistically significant association between LAE and LVO (p = 0.028). No significant difference was demonstrated between groups for the baseline AF and other clinical characteristics, except for baseline NIHSS (p = 0.0005). There was excellent inter- and intra-rater reliability (ICC = 0.969) for LA measurements. Conclusion Our study provides preliminary data to suggest LAE is more prevalent in the LVO stroke subgroup at presentation and can be reliably assessed on non-gated CT in the hyperacute setting. These findings have potential implications for stratifying secondary management and may prompt a more rigorous pursuit of occult AF or other cardiac causes of stroke.
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Affiliation(s)
- Waleed Butt
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Robert Lenthall
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Luqman Malik
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Wazim Izzath
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Kailash Krishnan
- Stroke Medicine, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Bindu George
- Cardiothoracic Radiology Department, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Kate Pointon
- Cardiothoracic Radiology Department, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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22
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Podlasek A, Dhillon PS, Jewett G, Shahein A, Goyal M, Almekhlafi M. Clinical and Procedural Outcomes with or without Balloon Guide Catheters during Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis with First-line Technique Subgroup Analysis. AJNR Am J Neuroradiol 2021; 42:1464-1471. [PMID: 34045301 DOI: 10.3174/ajnr.a7164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/16/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Balloon guide catheters are increasingly used to improve clot retrieval by temporarily stopping proximal blood flow during endovascular thrombectomy. PURPOSE Our aim was to provide a summary of the literature comparing the procedural and clinical outcomes of endovascular thrombectomy with or without balloon guide catheters, depending on the first-line technique used. DATA SOURCES We used PubMed/MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. STUDY SELECTION We chose studies that compared using balloon guide catheters with not using them. DATA ANALYSIS Random effects meta-analysis was performed to compare the procedural outcomes measured as the first-pass effect, successful reperfusion, number of passes, procedural duration, arterial puncture to reperfusion time, distal emboli, and clinical outcomes. DATA SYNTHESIS Overall, a meta-analysis of 16 studies (5507 patients, 50.8% treated with balloon guide catheters and 49.2% without them) shows that the use of balloon guide catheters increases the odds of achieving a first-pass effect (OR = 1.92; 95% CI, 1.34-2.76; P < .001), successful reperfusion (OR = 1.85; 95% CI, 1.42-2.40; P < .001), and good functional outcome (OR =1.48; 95% CI, 1.27-1.73; P < .001). Balloon guide catheters reduce the number of passes (mean difference = -0.35; 95% CI, -0.65 to -0.04; P = .02), procedural time (mean difference = -19.73; 95% CI, -34.63 to -4.83; P = .009), incidence of distal or new territory emboli (OR = 0.5; 95% CI, 0.26-0.98; P = .04), and mortality (OR = 0.72; 95% CI, 0.62-0.85; P < .001). Similar benefits of balloon guide catheters are observed when the first-line technique was a stent retriever or contact aspiration, but not for a combined approach. LIMITATIONS The analysis was based on nonrandomized trials with a moderate risk of bias. CONCLUSIONS Current literature suggests improved clinical and procedural outcomes associated with the use of balloon guide catheters during endovascular thrombectomy, especially when using the first-line stent retriever.
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Affiliation(s)
- A Podlasek
- From the Department of Neuroscience and Vascular Simulation (A.P.), School of Medicine, Anglia Ruskin University, Chelmsford, Essex, UK
- National Institute of Health Research Nottingham Biomedical Research Centre (A.P., P.S.D.), University of Nottingham, Nottingham, UK
- Clinical Radiology (A.P., P.S.D.), Queens Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - P S Dhillon
- National Institute of Health Research Nottingham Biomedical Research Centre (A.P., P.S.D.), University of Nottingham, Nottingham, UK
- Clinical Radiology (A.P., P.S.D.), Queens Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - G Jewett
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - A Shahein
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
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23
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Podlasek A, Dhillon PS, Butt W, Grunwald IQ, England TJ. Direct mechanical thrombectomy without intravenous thrombolysis versus bridging therapy for acute ischemic stroke: A meta-analysis of randomized controlled trials. Int J Stroke 2021; 16:621-631. [PMID: 34003709 DOI: 10.1177/17474930211021353] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Direct mechanical thrombectomy may result in similar outcomes compared to a bridging approach with intravenous thrombolysis (IVT + MT) in acute ischemic stroke. Recent randomized controlled trials have varied in their design and noninferiority margin. AIM We sought to meta-analyze accumulated trial data to assess the difference and non-inferiority in clinical and procedural outcomes between direct mechanical thrombectomy and bridging therapy. SUMMARY OF REVIEW We conducted a systematic review of electronic databases following the preferred reporting items for systematic reviews and meta-analyses guidelines. Random effects meta-analyses were conducted for the pooled data. The primary outcome was good functional outcome at 90 days (modified Rankin scale (mRS) ≤ 2). Secondary outcomes included excellent functional outcome (mRS ≤ 1), mortality, any intracranial hemorrhage, symptomatic intracranial hemorrhage, successful reperfusion (thrombolysis in cerebral infarction ≥ 2 b), and procedure-related complications. Four randomized controlled trials comprising 1633 patients (817 direct mechanical thrombectomy, 816 bridging therapy) were included. There were no statistical differences for the 90-day good functional outcome (OR = 1.02, 95% CI 0.84-1.25, p = 0.54, I2 = 0%), and the absolute risk difference was 1% (95% CI: -4% to 5%). The lower 95% CI falls within the strictest noninferiority margin of -10% among included randomized control trials. Direct mechanical thrombectomy reduced the odds of successful reperfusion (OR = 0.76, 95% CI: 0.60-0.97, p = 0.03, I2 = 0%) and any intracranial hemorrhage (OR = 0.65, 95% CI: 0.49-0.86, p = 0.003, I2 = 38%). There was no difference in the remaining secondary outcomes. The risk of bias for all studies was low. CONCLUSION The combined trial data assessing direct mechanical thrombectomy versus bridging therapy showed no difference in improving good functional outcome. The wide noninferiority thresholds set by individual trials are in contrast with the clinical consensus on minimally important differences. However, our pooled analysis indicates noninferiority of direct mechanical thrombectomy with a 4% margin of confidence. The application of these findings is limited to patients presenting directly to mechanical thrombectomy-capable centers and real-world workflow times may differ against those achieved in a trial setting.
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Affiliation(s)
- Anna Podlasek
- NIHR Nottingham Biomedical Research Center, University of Nottingham, Nottingham, UK.,Neuroscience and Vascular Simulation, 2369Anglia Ruskin University, Cambridge, UK
| | - Permesh Singh Dhillon
- NIHR Nottingham Biomedical Research Center, University of Nottingham, Nottingham, UK.,Interventional Neuroradiology, 9820Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, 9820Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iris Q Grunwald
- Neuroscience and Vascular Simulation, 2369Anglia Ruskin University, Cambridge, UK.,Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
| | - Timothy J England
- Stroke, Division of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, UK.,Stroke, 2102University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
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24
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Dhillon PS, McConachie N, Lenthall R, Nair S, Izzath W. Use of 8Fr angio-seal for closure of femoral arteriotomy following use of 8Fr and 9Fr sheaths in patients undergoing mechanical thrombectomy for acute ischaemic stroke. J Clin Neurosci 2021; 88:277-280. [PMID: 33992197 DOI: 10.1016/j.jocn.2021.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/23/2021] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little is known about the safety of off-label use of an 8Fr Angio-Seal VIP for large-bore arteriotomies in patients treated with mechanical thrombectomy (MT) and intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS). We aimed to identify differences in the groin complication rate using an 8Fr Angio-Seal VIP for common femoral arteriotomy closures following the use of 8Fr and 9Fr sheaths. METHODS All AIS patients who underwent MT at our tertiary neuroscience unit between January 2018 and March 2020 were retrospectively reviewed. RESULTS 161 patients were included in the study, of whom 56 and 105 patients underwent an arteriotomy using an 8Fr sheath (36 of them receiving IVT) and a 9Fr sheath (57 of them receiving IVT). Overall, 17 groin complications were identified (10.5%) in 5 patients (8.9%) who had had 8Fr sheaths inserted and 12 patients (11.4%) who had had 9Fr sheaths inserted. Major complications were identified in only 2 patients (1.2%), one patient in each of the 8Fr and 9Fr cohorts suffering a pseudoaneurysm requiring intervention. No retroperitoneal haematoma, infection, acute limb ischaemia or ipsilateral DVT was identified. No significant difference in groin complications was observed between the 8Fr and 9Fr femoral arteriotomy cohorts or between the MT patients that did or did not receive adjunctive IVT. CONCLUSION In the setting of MT with IVT, off-label use of an 8Fr Angio-Seal VIP for closure of a femoral arteriotomy following use of a 9Fr sheath has a similar safety profile to the licensed use of an 8Fr Angio-Seal VIP for closure of a femoral arteriotomy following use of an 8Fr sheath or smaller.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
| | - Norman McConachie
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Robert Lenthall
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Sujit Nair
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Wazim Izzath
- Interventional Neuroradiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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25
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Butt W, Dhillon PS, Podlasek A, Malik L, Nair S, Hewson D, England TJ, Lenthall R, McConachie N. Local anesthesia as a distinct comparator versus conscious sedation and general anesthesia in endovascular stroke treatment: a systematic review and meta-analysis. J Neurointerv Surg 2021; 14:221-226. [PMID: 33758063 DOI: 10.1136/neurintsurg-2021-017360] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 01/22/2021] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The optimal anesthetic modality for endovascular treatment (EVT) in acute ischemic stroke (AIS) is undetermined. Comparisons of general anesthesia (GA) with composite non-GA cohorts of conscious sedation (CS) and local anesthesia (LA) without sedation have provided conflicting results. There has been emerging interest in assessing whether LA alone may be associated with improved outcomes. We conducted a systematic review and meta-analysis to evaluate clinical and procedural outcomes comparing LA with CS and GA. METHODS We reviewed the literature for studies reporting outcome variables in LA versus CS and LA versus GA comparisons. The primary outcome was 90 day good functional outcome (modified Rankin Scale (mRS) score of ≤2). Secondary outcomes included mortality, symptomatic intracerebral hemorrhage, excellent functional outcome (mRS score ≤1), successful reperfusion (Thrombolysis in Cerebral Infarction (TICI) >2b), procedural time metrics, and procedural complications. Random effects meta-analysis was performed on unadjusted and adjusted data. RESULTS Eight non-randomized studies of 7797 patients (2797 LA, 2218 CS, and 2782 GA) were identified. In the LA versus GA comparison, no statistically significant differences were found in unadjusted analyses for 90 day good functional outcome or mortality (OR=1.22, 95% CI 0.84 to 1.76, p=0.3 and OR=0.83, 95% CI 0.64 to 1.07, p=0.15, respectively) or in the LA versus CS comparison (OR=1.14, 95% CI 0.76 to 1.71, p=0.53 and OR=0.88, 95% CI 0.62 to 1.24, p=0.47, respectively). There was a tendency towards achieving excellent functional outcome (mRS ≤1) in the LA group versus the GA group (OR=1.44, 95% CI 1.00 to 2.08, p=0.05, I2=70%). Analysis of adjusted data demonstrated a tendency towards higher odds of death at 90 days in the GA versus the LA group (OR=1.24, 95% CI 1.00 to 1.54, p=0.05, I2=0%). CONCLUSION LA without sedation was not significantly superior to CS or GA in improving outcomes when performing EVT for AIS. However, the quality of the included studies impaired interpretation, and inclusion of an LA arm in future well designed multicenter, randomized controlled trials is warranted.
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Affiliation(s)
- Waleed Butt
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Permesh Singh Dhillon
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, Nottinghamshire, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, Nottingham, Nottinghamshire, UK
| | - Luqman Malik
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David Hewson
- Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Vascular Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.,Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Norman McConachie
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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26
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Butt W, Malik L, Dhillon PS, McConachie N. Flow-related posterior cerebral artery aneurysms with internal carotid artery occlusions: An institutional series. Interv Neuroradiol 2021; 27:631-637. [PMID: 33673757 DOI: 10.1177/15910199211001702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Aneurysm formation after internal carotid artery (ICA) occlusion has been described in animal models and human case series with alteration of cerebral blood flow dynamics considered an aetiological risk factor. Such de novo aneurysms have seldom been described in the posterior cerebral artery (PCA) with the majority observed in the anterior circulation collateral pathways. METHODS We retrospectively reviewed our institutional database of posterior circulation aneurysms in patients with iatrogenic, atherosclerotic or congenital ICA occlusions. A comprehensive review of the online literature using the PubMed and Medline databases was performed to identify previous cases of PCA aneurysms that were considered 'flow-related'. RESULTS We present five patients with symptomatic or ruptured PCA aneurysms with ICA occlusions. Age at presentation ranged from 21-58 and aneurysm size from 3-12 mm. All cases had angiographic evidence of posterior-anterior flow via the ipsilateral posterior communicating artery (PComA). The clinical presentation, diagnostic imaging and management strategies are further discussed. A literature review identified only two previous reported cases. CONCLUSION To our knowledge this is the first single centre series of posterior circulation aneurysms in patients with ICA occlusions that are considered to be 'flow-related.' The natural history of these rare lesions is unclear and the best management and surveillance strategy requires a patient-tailored approach by an experienced neurovascular team.
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Affiliation(s)
- Waleed Butt
- Interventional Neuroradiology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Permesh Singh Dhillon
- Interventional Neuroradiology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Dhillon PS, Dineen RA, Morris H, Tanasescu R, Nikfekr E, Evans J, Constantinescu CS, Hosseini AA. Neurological Disorders Associated With COVID-19 Hospital Admissions: Experience of a Single Tertiary Healthcare Center. Front Neurol 2021; 12:640017. [PMID: 33679593 PMCID: PMC7934891 DOI: 10.3389/fneur.2021.640017] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/26/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Early reports have detailed a range of neurological symptoms in patients with the SARS-CoV-2 infection. However, there is a lack of detailed description and incidence of the neurological disorders amongst hospitalized COVID-19 patients. We describe a range of neurological disorders (other than non-specific neurological symptoms), including their clinical, radiological, and laboratory findings, encountered in our cohort of COVID-19 patients admitted to a large tertiary institution. Methods: We reviewed our prospectively collated database of all adult Neurology referrals, Neurology and Stroke admissions and Neurological multi-disciplinary team meetings for all hospitalized patients with suspected or proven COVID-19 from 17 March 2020 to 31 August 2020. Results: Twenty-nine of 1,243 COVID-19 inpatients (2.3%) presented with COVID-19-related neurological disorders. The mean age was 68.9 ± 13.5(SD) years, age range of 34–97 years, and there were 16 males. Twenty two patients had confirmed, five were probable and two had suspected COVID-19 infection according to the WHO case classification. Eight patients (27%) required critical care admission. Neurological symptoms at presentation included acute confusion and delirium, seizures, and new focal neurological deficits. Based on the pre-defined neurological phenotype, COVID-19 patients were grouped into four main categories. Sixteen patients had cerebrovascular events (13 with acute ischemic stroke and three had hemorrhagic features), seven patients were found to have inflammatory, non-inflammatory and autoimmune encephalopathy (including two with known Multiple Sclerosis), whilst disorders of movement and peripheral nervous system were diagnosed in three patients each. Conclusion: Although the exact prevalence and etiology remain unclear, new onset of neurological disorders, in addition to anosmia, is non-sporadic during the acute COVID-19-infection. Longitudinal follow-up of these patients is required to determine the clinical and functional outcome, treatment response and long-term effects of the SARS-CoV-2 infection.
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Affiliation(s)
- Permesh Singh Dhillon
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.,NIHR Nottingham Biomedical Research Centre, Nottingham, United Kingdom
| | - Robert A Dineen
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,NIHR Nottingham Biomedical Research Centre, Nottingham, United Kingdom
| | - Haley Morris
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Radu Tanasescu
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Esmaeil Nikfekr
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Jonathan Evans
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Cris S Constantinescu
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Akram A Hosseini
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Dhillon PS, Lenthall R. Letter by Dhillon and Lenthall Regarding Article, "Infarction of the Splenium of the Corpus Callosum in the Age of COVID-19: A Snapshot in Time". Stroke 2020; 51:e378-e379. [PMID: 33226917 DOI: 10.1161/strokeaha.120.032156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Permesh Singh Dhillon
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, United Kingdom (P.S.D., R.L.).,Division of Clinical Neuroscience, Department of Radiological Sciences, University of Nottingham, United Kingdom (P.S.D.).,NIHR Nottingham Biomedical Research Centre, United Kingdom (P.S.D.)
| | - Robert Lenthall
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, United Kingdom (P.S.D., R.L.)
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Dhillon PS, Chattopadhyay A, Dineen RA, Lenthall R. Hemorrhagic Neurologic Manifestations in COVID-19: An Isolated or Multifactorial Cause? AJNR Am J Neuroradiol 2020; 41:E89-E90. [PMID: 33033044 DOI: 10.3174/ajnr.a6795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- P S Dhillon
- Neuroradiology Department Queen's Medical CentreNottingham University Hospitals National Health Service TrustNottingham, UK.,Radiological Sciences, Division of Clinical NeuroscienceUniversity of NottinghamNottingham, UK
| | - A Chattopadhyay
- Neuroradiology DepartmentQueen's Medical CentreNottingham University Hospitals National Health Service TrustNottingham, UK
| | - R A Dineen
- Radiological Sciences, Division of Clinical NeuroscienceUniversity of NottinghamNottingham, UK.,National Institute for Health Research Nottingham Biomedical Research CentreNottingham, UK
| | - R Lenthall
- Neuroradiology DepartmentQueen's Medical CentreNottingham University Hospitals National Health ServiceTrustNottingham, UK
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Dhillon PS, Pointon K, Lenthall R, Nair S, Subramanian G, McConachie N, Izzath W. Regional Mechanical Thrombectomy Imaging Protocol in Patients Presenting with Acute Ischemic Stroke during the COVID-19 Pandemic. AJNR Am J Neuroradiol 2020; 41:1849-1855. [PMID: 32819897 PMCID: PMC7661079 DOI: 10.3174/ajnr.a6754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Chest CT is a rapid, useful additional screening tool for coronavirus disease 2019 (COVID-19) in emergent procedures. We describe the feasibility and interim outcome of implementing a modified imaging algorithm for COVID-19 risk stratification across a regional network of primary stroke centers in the work-up of acute ischemic stroke referrals for time-critical mechanical thrombectomy. MATERIALS AND METHODS We undertook a retrospective review of 49 patients referred to the regional neuroscience unit for consideration of mechanical thrombectomy between April 14, 2020, and May 21, 2020. During this time, all referring units followed a standard imaging protocol that included a chest CT in addition to a head CT and CT angiogram to identify Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infective pulmonary changes. RESULTS Overall, 2 patients had typical COVID-19 radiologic features and tested positive, while 7 patients had indeterminate imaging findings and tested negative. The others had normal or atypical changes and were not diagnosed with or suspected of having COVID-19. There was an overall sensitivity of 100%, specificity of 74.1%, negative predictive value of 100%, and positive predictive value of 22.2% when using chest CT to diagnose COVID-19 in comparison with the real-time reverse transcriptase-polymerase chain reaction test. The mean additional time and radiation dose incurred for the chest CT were 184 ± 65.5 seconds and 2.47 ± 1.03 mSv. Multiple cardiovascular and pulmonary incidental findings of clinical relevance were identified in our patient population. CONCLUSIONS Chest CT provides a pragmatic, rapid additional tool for COVID-19 risk stratification among patients referred for mechanical thrombectomy. Its inclusion in a standardized regional stroke imaging protocol has enabled efficient use of hospital resources with minimal compromise or delay to the overall patient treatment schedule.
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Affiliation(s)
- P S Dhillon
- From the Interventional Neuroradiology Department (P.S.D., R.L., S.N., N.M., W.I.), Queen's Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - K Pointon
- Cardiothoracic Radiology Department (K.P.)
| | - R Lenthall
- From the Interventional Neuroradiology Department (P.S.D., R.L., S.N., N.M., W.I.), Queen's Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - S Nair
- From the Interventional Neuroradiology Department (P.S.D., R.L., S.N., N.M., W.I.), Queen's Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - G Subramanian
- Stroke Medicine Department (G.S.), Nottingham City Hospital, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - N McConachie
- From the Interventional Neuroradiology Department (P.S.D., R.L., S.N., N.M., W.I.), Queen's Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - W Izzath
- From the Interventional Neuroradiology Department (P.S.D., R.L., S.N., N.M., W.I.), Queen's Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
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Awwad A, Dhillon PS, Ramjas G, Habib SB, Al-Obaydi W. Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre. CVIR Endovasc 2018; 1:32. [PMID: 30652163 PMCID: PMC6319536 DOI: 10.1186/s42155-018-0031-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/01/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm. MAIN BODY Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE. CONCLUSION Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.
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Affiliation(s)
- Amir Awwad
- NIHR Nottingham Biomedical Research Centre, Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, NG72UH UK
- Radiology Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, CB23 3RE UK
| | - Permesh Singh Dhillon
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
- NIHR Nottingham Biomedical Research Centre, Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, NG72UH UK
| | - Greg Ramjas
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Said B. Habib
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Waleed Al-Obaydi
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
- Interventional Radiology, Royal Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE UK
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Dhillon PS, Butt MW, Pollock G, Kirk J, Bungay P, De Nunzio M, Thurley P. Incidental extravascular findings in CT angiograms in patients post endovascular abdominal aortic aneurysm repair: clinical relevance and frequency. CVIR Endovasc 2018. [PMCID: PMC6966401 DOI: 10.1186/s42155-018-0016-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background To evaluate the incidence and clinical relevance of extravascular incidental findings (EVIF), particularly malignancies, in planning and follow-up CT angiograms (CTA) of the abdominal aorta in patients who underwent endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. Retrospective study of 2203 planning and follow-up CTAs of 418 patients who underwent EVAR in a single tertiary centre between 2006 and 2015. CTA reports were scrutinized for EVIFs, which were classified according to clinical relevance, into (I) immediate, (II) potential and (III) no clinical relevance. Clinical follow-up and management were reviewed for significant findings. Follow-up CTAs of patients with incidental malignancies were re-reviewed by two consultant radiologists to evaluate if early missed malignant findings on previous CTAs were present. Results In total, 950 EVIFs were noted in 418 patients [31 females (7.4%), 387 males (92.6%); age range 63–93, mean age 79.0 years]. The number of patients with findings in each category were; Category I (115), Category II (165), Category III (304). Incidental malignant findings were reported in 51 patients (12.2%), of which 27 were noted on the initial CTA (6.5%) and 24 on follow-up CTAs (5.7%). Of the 24 patients with malignancies on follow-up CTAs, 13 had early malignant findings missed or misinterpreted on previous CTAs, while 11 had no significant abnormality even on retrospective review. Conclusion A high number of significant EVIFs, particularly incidental malignancies, can be identified in follow-up CTAs of patients who undergo EVAR. Specific ‘review areas’ when reporting surveillance CTAs can be recommended based on the findings of our study.
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Dhillon PS, Habib S. Inferior Vena Cava Filter Retrieval: A National Survey of Current Practice. Cardiovasc Intervent Radiol 2018; 41:1451-1452. [PMID: 29663051 DOI: 10.1007/s00270-018-1956-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Permesh Singh Dhillon
- Interventional Radiology, Radiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
- Radiological Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK.
| | - Said Habib
- Interventional Radiology, Radiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
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Sperry MM, Kandel BM, Wehrli S, Bass KN, Das SR, Dhillon PS, Gee JC, Barr GA. Mapping of pain circuitry in early post-natal development using manganese-enhanced MRI in rats. Neuroscience 2017; 352:180-189. [PMID: 28391012 PMCID: PMC7276061 DOI: 10.1016/j.neuroscience.2017.03.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/08/2017] [Accepted: 03/28/2017] [Indexed: 12/14/2022]
Abstract
Premature or ill full-term infants are subject to a number of noxious procedures as part of their necessary medical care. Although we know that human infants show neural changes in response to such procedures, we know little of the sensory or affective brain circuitry activated by pain. In rodent models, the focus has been on spinal cord and, more recently, midbrain and medulla. The present study assesses activation of brain circuits using manganese-enhanced magnetic resonance imaging (MEMRI). Uptake of manganese, a paramagnetic contrast agent that is transported across active synapses and along axons, was measured in response to a hindpaw injection of dilute formalin in 12-day-old rat pups, the age at which rats begin to show aversion learning and which is roughly the equivalent of full-term human infants. Formalin induced the oft-reported biphasic response at this age and induced a conditioned aversion to cues associated with its injection, thus demonstrating the aversiveness of the stimulation. Morphometric analyses, structural equation modeling and co-expression analysis showed that limbic and sensory paths were activated, the most prominent of which were the prefrontal and anterior cingulate cortices, nucleus accumbens, amygdala, hypothalamus, several brainstem structures, and the cerebellum. Therefore, both sensory and affective circuits, which are activated by pain in the adult, can also be activated by noxious stimulation in 12-day-old rat pups.
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Affiliation(s)
- M M Sperry
- Department of Bioengineering, University of Pennsylvania, United States
| | - B M Kandel
- Penn Image Computing and Science Laboratory, Department of Radiology, University of Pennsylvania, United States
| | - S Wehrli
- NMR Core, Children's Hospital of Philadelphia, United States
| | - K N Bass
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, United States
| | - S R Das
- Penn Image Computing and Science Laboratory, Department of Radiology, University of Pennsylvania, United States
| | - P S Dhillon
- Penn Image Computing and Science Laboratory, Department of Radiology, University of Pennsylvania, United States
| | - J C Gee
- Penn Image Computing and Science Laboratory, Department of Radiology, University of Pennsylvania, United States
| | - G A Barr
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, United States.
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Affiliation(s)
- Permesh Singh Dhillon
- Royle Eye Department, Pilgrim Hospital, Boston, United Lincolnshire Hospitals Trust, Boston, UK
| | - Gareth Lewis
- Royle Eye Department, Pilgrim Hospital, Boston, United Lincolnshire Hospitals Trust, Boston, UK
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Abstract
Various ophthalmic complications affecting the anterior and posterior segments have been identified due to lightning strike. We report the first case of an indirect lightning-induced full thickness macular hole formation in the UK as evidenced by slit lamp examination and optical coherence tomography (OCT) scan in a 77-year-old woman presenting with sudden visual loss in her right eye and thermal skin injury affecting her scalp. Her best corrected visual acuities were LogMAR 0.46 and 0.12 in the right and left eyes, respectively. There were no other ocular manifestations observed in either eye. She was initially managed conservatively with non-steroidal anti-inflammatory drug eye drops but surgery was later advised due to minimal changes in the visual acuity and macular hole on follow-up. OCT scanning is important in diagnosing macular holes, which usually warrant surgical intervention.
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Affiliation(s)
- Permesh Singh Dhillon
- Royle Eye Department, Pilgrim Hospital, United Lincolnshire Hospitals Trust, Boston, UK
| | - Mohit Gupta
- Royle Eye Department, Pilgrim Hospital, United Lincolnshire Hospitals Trust, Boston, UK
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Hashmani K, Branch MJ, Sidney LE, Dhillon PS, Verma M, McIntosh OD, Hopkinson A, Dua HS. Characterization of corneal stromal stem cells with the potential for epithelial transdifferentiation. Stem Cell Res Ther 2013; 4:75. [PMID: 23800436 PMCID: PMC4058700 DOI: 10.1186/scrt226] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 06/04/2013] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The corneal stroma is being increasingly recognized as a repository for stem cells. Like the limbal and endothelial niches, stromal stem cells often reside in the peripheral cornea and limbus. These peripheral and limbal corneal stromal cells (PLCSCs) are known to produce mesenchymal stem cells in vitro. Recently, a common corneal stromal and epithelial progenitor was hinted at. This study aims to examine the stem cell potential of corneal stromal cells and to investigate their epithelial transdifferentiation ability. METHODS PLCSCs were grown in traditional Dulbecco modified Eagle medium (DMEM)-based keratocyte culture medium and an M199-based medium and analyzed for a profile of cell-surface markers by using flow cytometry and differentiated into mesenchymal phenotypes analyzed with quantitative polymerase chain reaction (qPCR) and histologic staining. PLCSCs in M199 were subsequently divided into subpopulations based on CD34 and CD105 expression by using fluorescence- activated cell sorting (FACS). Subpopulations were characterized by marker profile and mesenchymal differentiation ability. Both whole PLCSCs and subpopulations were also cultured for epithelial transdifferentiation. RESULTS Cells cultured in M199 demonstrated a more stem-like cell-surface marker profile, and the keratocyte marker CD34 was retained for several passages but absent in cells cultured in DMEM. Cells cultured in M199 also exhibited a greater mesenchymal differentiation potential, compared with DMEM. PLCSCs could be divided into CD34(+)CD105(+), CD34-CD105(+), and CD34-CD105- subpopulations, of which CD34(+)CD105(+) cells were the most stemlike with regard to marker expression and mesenchymal differentiation potential. Subpopulations of PLCSCs exhibited differing abilities to transdifferentiate into epithelial phenotypes. Cells that were initially CD34(+)CD105(+) showed the greatest differentiation potential, producing CK3(+) and CK19(+) cells, and expressed a range of both epithelial progenitor (HES1, FRZB1, DCT, SOD2, ABCG2, CDH1, KRT19) and terminally differentiated (DSG3, KRT3, KRT12, KRT24) genes. CONCLUSIONS Culture medium has a significant effect on the phenotype and differentiation capacity of PLCSCs. The stroma contains a heterogeneous cell population in which we have identified CD34(+) cells as a stem cell population with a capacity for mesenchymal and epithelial differentiation.
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Abstract
Plastic deformation refers to the deformation of a bone, without fracture of its cortices, that persists once the deforming force has been removed. It is not a common condition but is seen more frequently in children than in adults. Of the cases published, there have been only three previous reports of tibial involvement, with the forearm being the most commonly affected site. We describe the case of a 10-year-old girl who, after falling down a slope, came to a sudden stop when her right foot hit a rock. This resulted in a fracture of the fibula and bowing of the tibia. We discuss the dilemmas faced in treatment and recommend regular follow up until the patient reaches skeletal maturity.
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Affiliation(s)
- P S Dhillon
- Weston General Hospital, Weston-super-Mare, Somerset, UK.
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Gul S, Dhillon PS, Verma C, Thomas EW, Brocklehurst K. Investigation of electrostatic interactions and binding effects in papin-ligand interaction. Biochem Soc Trans 1996; 24:473S. [PMID: 8879017 DOI: 10.1042/bst024473s] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- S Gul
- Department of Biochemistry, Queen Mary and Westfield College, University of London, U.K
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Hodgson JM, Graham SP, Savakus AD, Dame SG, Stephens DN, Dhillon PS, Brands D, Sheehan H, Eberle MJ. Clinical percutaneous imaging of coronary anatomy using an over-the-wire ultrasound catheter system. Int J Card Imaging 1989; 4:187-93. [PMID: 2527918 DOI: 10.1007/bf01745149] [Citation(s) in RCA: 160] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This manuscript describes initial applications of a unique new intravascular ultrasound imaging catheter. This 5.5F catheter uses an over-the-wire design and incorporates a phased array transducer at its tip. There are no moving parts. A 360 degree image is produced perpendicular to the catheter axis using a 20 MHz center frequency. A dedicated minicomputer is used for initial image processing, as well as enhancement and analysis. Initial studies using phantoms demonstrated excellent accuracy for linear dimensions (r = 0.99, range 3.0 to 7.6 mm, image = 1.0 phantom + 0.1). Serial imaging of the same arterial segment in vitro showed good reproducibility (coefficients of variance 2.5-5.2%). Likewise, intra- and inter-observer variability in image analysis was minimal (r = 0.92-0.99). Initial in vivo studies were performed in dogs. The catheter was easily passed over a wire into mesenteric, cerebral and coronary vessels without evidence of significant vessel trauma. Subsequently, 20 patients had percutaneous coronary imaging performed during cardiac catheterization. Cardiac motion was rarely a problem and acceptable images were obtained in all but two patients. Areas of calcification, mild stenoses, branching vessels and graft atherosclerosis could be identified. We conclude that intracoronary ultrasound imaging will be useful for assessing vascular pathology, for studying both rapid change in vessel size as well as chronic progression or regression of atherosclerosis, and for assisting with new therapeutic interventions.
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Affiliation(s)
- J M Hodgson
- Division of Cardiology, McGuire VAMC, Richmond, VA
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