1
|
Kamogawa N, Miwa K, Toyoda K, Jensen M, Inoue M, Yoshimura S, Fukuda-Doi M, Kitazono T, Boutitie F, Ma H, Ringleb P, Wu O, Schwamm LH, Warach S, Hacke W, Davis SM, Donnan GA, Gerloff C, Thomalla G, Koga M. Thrombolysis for Wake-Up Stroke Versus Non-Wake-Up Unwitnessed Stroke: EOS Individual Patient Data Meta-Analysis. Stroke 2024; 55:895-904. [PMID: 38456303 PMCID: PMC10978262 DOI: 10.1161/strokeaha.123.043358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Stroke with unknown time of onset can be categorized into 2 groups; wake-up stroke (WUS) and unwitnessed stroke with an onset time unavailable for reasons other than wake-up (non-wake-up unwitnessed stroke, non-WUS). We aimed to assess potential differences in the efficacy and safety of intravenous thrombolysis (IVT) between these subgroups. METHODS Patients with an unknown-onset stroke were evaluated using individual patient-level data of 2 randomized controlled trials (WAKE-UP [Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke], THAWS [Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes With Alteplase at 0.6 mg/kg]) comparing IVT with placebo or standard treatment from the EOS (Evaluation of Unknown-Onset Stroke Thrombolysis trial) data set. A favorable outcome was prespecified as a modified Rankin Scale score of 0 to 1 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage at 22 to 36 hours and 90-day mortality. The IVT effect was compared between the treatment groups in the WUS and non-WUS with multivariable logistic regression analysis. RESULTS Six hundred thirty-four patients from 2 trials were analyzed; 542 had WUS (191 women, 272 receiving alteplase), and 92 had non-WUS (42 women, 43 receiving alteplase). Overall, no significant interaction was noted between the mode of onset and treatment effect (P value for interaction=0.796). In patients with WUS, the frequencies of favorable outcomes were 54.8% and 45.5% in the IVT and control groups, respectively (adjusted odds ratio, 1.47 [95% CI, 1.01-2.16]). Death occurred in 4.0% and 1.9%, respectively (P=0.162), and symptomatic intracranial hemorrhage in 1.8% and 0.3%, respectively (P=0.194). In patients with non-WUS, no significant difference was observed in favorable outcomes relative to the control (37.2% versus 29.2%; adjusted odds ratio, 1.76 [0.58-5.37]). One death and one symptomatic intracranial hemorrhage were reported in the IVT group, but none in the control. CONCLUSIONS There was no difference in the effect of IVT between patients with WUS and non-WUS. IVT showed a significant benefit in patients with WUS, while there was insufficient statistical power to detect a substantial benefit in the non-WUS subgroup. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: CRD42020166903.
Collapse
Affiliation(s)
- Naruhiko Kamogawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Center for Advancing Clinical and Translational Sciences, National Cerebral, and Cardiovascular Center, Suita, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France; Université Lyon 1, Villeurbanne, France; Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Steven Warach
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, the University of Melbourne, Melbourne, VIC, Australia
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, the University of Melbourne, Melbourne, VIC, Australia
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
2
|
Walter J, Alhalabi OT, Schönenberger S, Ringleb P, Vollherbst DF, Möhlenbruch M, Unterberg A, Neumann JO. Prior Thrombectomy Does Not Affect the Surgical Complication Rate of Decompressive Hemicraniectomy in Patients with Malignant Ischemic Stroke. Neurocrit Care 2024; 40:698-706. [PMID: 37639204 PMCID: PMC10959817 DOI: 10.1007/s12028-023-01820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Even though mechanical recanalization techniques have dramatically improved acute stroke care since the pivotal trials of decompressive hemicraniectomy for malignant courses of ischemic stroke, decompressive hemicraniectomy remains a mainstay of malignant stroke treatment. However, it is still unclear whether prior thrombectomy, which in most cases is associated with application of antiplatelets and/or anticoagulants, affects the surgical complication rate of decompressive hemicraniectomy and whether conclusions derived from prior trials of decompressive hemicraniectomy are still valid in times of modern stroke care. METHODS A total of 103 consecutive patients who received a decompressive hemicraniectomy for malignant middle cerebral artery infarction were evaluated in this retrospective cohort study. Surgical and functional outcomes of patients who had received mechanical recanalization before surgery (thrombectomy group, n = 49) and of patients who had not received mechanical recanalization (medical group, n = 54) were compared. RESULTS The baseline characteristics of the two groups did significantly differ regarding preoperative systemic thrombolysis (63.3% in the thrombectomy group vs. 18.5% in the medical group, p < 0.001), the rate of hemorrhagic transformation (44.9% vs. 24.1%, p = 0.04) and the preoperative Glasgow Coma Score (median of 7 in the thrombectomy group vs. 12 in the medical group, p = 0.04) were similar to those of prior randomized controlled trials of decompressive hemicraniectomy. There was no significant difference in the rates of surgical complications (10.2% in the thrombectomy group vs. 11.1% in the medical group), revision surgery within the first 30 days after surgery (4.1% vs. 5.6%, respectively), and functional outcome (median modified Rankin Score of 4 at 5 and 14 months in both groups) between the two groups. CONCLUSIONS A prior mechanical recanalization with possibly associated systemic thrombolysis does not affect the early surgical complication rate and the functional outcome after decompressive hemicraniectomy for malignant ischemic stroke. Patient characteristics have not changed significantly since the introduction of mechanical recanalization; therefore, the results from former large randomized controlled trials are still valid in the modern era of stroke care.
Collapse
Affiliation(s)
- Johannes Walter
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - O T Alhalabi
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - S Schönenberger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - D F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - A Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - J-O Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| |
Collapse
|
3
|
Burth S, Meis J, Kronsteiner D, Heckhausen H, Zweckberger K, Kieser M, Wick W, Ulfert C, Möhlenbruch M, Ringleb P, Schönenberger S. Outcome analysis for patients with subarachnoid hemorrhage and vasospasm including endovascular treatment. Neurol Res Pract 2023; 5:57. [PMID: 37915071 PMCID: PMC10621117 DOI: 10.1186/s42466-023-00283-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/14/2023] [Indexed: 11/03/2023] Open
Abstract
As a complication of subarachnoid hemorrhage (SAH), vasospasm substantially contributes to its morbidity and mortality. We aimed at analyzing predictors of outcome for these patients including the role of endovascular treatment (ET). Our database was screened for patients with SAH treated in our Neuro-ICU from 2009 to 2019. Clinical parameters including functional outcome (modified Rankin Scale, mRS of 0-2 or 3-6 at discharge and after a median follow-up of 18 months) and details about ET were gathered on 465 patients, 241 (52%) of whom experienced vasospasm. Descriptive analyses were performed to identify explanatory variables for the dichotomized mRS score. A logistic regression model was fitted on 241 patients with vasospasm including age, Hunt and Hess Score, extraventricular drainage (EVD), forced hypertension, ET and delayed cerebral ischemia (DCI). The model found a Hunt and Hess Score of 5 (OR = 0.043, p = 0.008), requirement of EVD (OR = 0.161, p < 0.001), forced hypertension (OR = 0.242, p = 0.001), ET (OR = 0.431, p = 0.043) and DCI (OR = 0.229, p < 0.001) to be negative predictors of outcome while age was not. Use of intraarterial nimodipine alone (OR = 0.778, p = 0.705) or including balloon angioplasty (OR = 0.894, p = 0.902) and number of ETs per patient (OR = 0.757, p = 0.416) were not significant in a separate model with otherwise identical variables. While DCI is clearly associated with poor outcome, the influence of ET on outcome remains inconclusive. Limited by their retrospective nature and an indication bias, these data encourage a randomized assessment of ET.
Collapse
Affiliation(s)
- Sina Burth
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Jan Meis
- Institute of Medical Biometry, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Helena Heckhausen
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Klaus Zweckberger
- Departement of Neurosurgery, Städtisches Klinikum Braunschweig gGmbH, Salzdahlumer Street 90, 38126, Braunschweig, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- DKFZ Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK) and Clinical Cooperation Unit Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| |
Collapse
|
4
|
Ringleb P, Bauer G, Purrucker J. [Intravenous thrombolysis of ischemic stroke-Current status]. Nervenarzt 2023:10.1007/s00115-023-01500-9. [PMID: 37249597 DOI: 10.1007/s00115-023-01500-9] [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] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023]
Abstract
Intravenous thrombolysis (IVT) treatment with alteplase (rtPA) is an essential part of the routine treatment of patients with ischemic stroke since its introduction in the late 1990s. Rapid treatment is of essential importance. For patients with an unclear time window, various mismatch concepts have been established to identify salvageable brain tissue prior to IVT. Numerous official contraindications for rtPA are not evidence-based; for example, current data from observational studies show that systemic thrombolytic treatment is possible even in patients receiving direct oral anticoagulant (DOAC) treatment. Tenecteplase (TNK) is an alternative thrombolytic agent with some pharmacologic advantages. The most recent guidelines indicate that TNK is particularly advantageous over rtPA in patients treated in combination with endovascular stroke therapy (EST). The combination of IVT and EST should primarily be performed in the 4.5‑h time window in patients without contraindications; in the later time window EST alone is conceivable if it can be performed without delay.
Collapse
Affiliation(s)
- Peter Ringleb
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Gregor Bauer
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Jan Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| |
Collapse
|
5
|
Traenka C, Lorscheider J, Hametner C, Baumgartner P, Gralla J, Magoni M, Martinez-Majander N, Casolla B, Feil K, Pascarella R, Papanagiotou P, Nordanstig A, Padjen V, Cereda CW, Psychogios M, Nolte CH, Zini A, Michel P, Béjot Y, Kastrup A, Zedde M, Kägi G, Kellert L, Henon H, Curtze S, Pezzini A, Arnold M, Wegener S, Ringleb P, Tatlisumak T, Nederkoorn PJ, Engelter ST, Gensicke H. Recanalization Therapies for Large Vessel Occlusion Due to Cervical Artery Dissection: A Cohort Study of the EVA-TRISP Collaboration. J Stroke 2023; 25:272-281. [PMID: 37282374 DOI: 10.5853/jos.2022.03370] [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: 10/26/2022] [Accepted: 02/27/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND AND PURPOSE This study aimed to investigate the effect of endovascular treatment (EVT, with or without intravenous thrombolysis [IVT]) versus IVT alone on outcomes in patients with acute ischemic stroke (AIS) and intracranial large vessel occlusion (LVO) attributable to cervical artery dissection (CeAD). METHODS This multinational cohort study was conducted based on prospectively collected data from the EVA-TRISP (EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients) collaboration. Consecutive patients (2015-2019) with AIS-LVO attributable to CeAD treated with EVT and/or IVT were included. Primary outcome measures were (1) favorable 3-month outcome (modified Rankin Scale score 0-2) and (2) complete recanalization (thrombolysis in cerebral infarction scale 2b/3). Odds ratios with 95% confidence intervals (OR [95% CI]) from logistic regression models were calculated (unadjusted, adjusted). Secondary analyses were performed in the patients with LVO in the anterior circulation (LVOant) including propensity score matching. RESULTS Among 290 patients, 222 (76.6%) had EVT and 68 (23.4%) IVT alone. EVT-treated patients had more severe strokes (National Institutes of Health Stroke Scale score, median [interquartile range]: 14 [10-19] vs. 4 [2-7], P<0.001). The frequency of favorable 3-month outcome did not differ significantly between both groups (EVT: 64.0% vs. IVT: 86.8%; ORadjusted 0.56 [0.24-1.32]). EVT was associated with higher rates of recanalization (80.5% vs. 40.7%; ORadjusted 8.85 [4.28-18.29]) compared to IVT. All secondary analyses showed higher recanalization rates in the EVT-group, which however never translated into better functional outcome rates compared to the IVT-group. CONCLUSION We observed no signal of superiority of EVT over IVT regarding functional outcome in CeAD-patients with AIS and LVO despite higher rates of complete recanalization with EVT. Whether pathophysiological CeAD-characteristics or their younger age might explain this observation deserves further research.
Collapse
Affiliation(s)
- Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Johannes Lorscheider
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Philipp Baumgartner
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology University Hospital Bern, University of Bern, Bern, Switzerland
| | - Mauro Magoni
- ASST Spedali Civili, Neurologia Vascolare, Brescia, Italy
| | | | - Barbara Casolla
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
- Stroke Unit, UR2CA-URRIS Neurology, CHU Pasteur 2, Nice Cote d'Azur University, Nice, France
| | - Katharina Feil
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
- Department of Neurology, University Hospital Tübingen, Tübingen, Germany
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Annika Nordanstig
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience Institute for Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Visnja Padjen
- University of Belgrade, Faculty of Medicine, Neurology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Carlo W Cereda
- Stroke Center, Department of Neurology, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Marios Psychogios
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Christian H Nolte
- Klinik für Neurologie mit experimenteller Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Germany
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Patrik Michel
- Stroke Service, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Yannick Béjot
- Department of Neurology, University Hospital Dijon, Dijon, France
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Ost, Bremen, Germany
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Hilde Henon
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Susanne Wegener
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience Institute for Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| |
Collapse
|
6
|
Meinel TR, Wilson D, Gensicke H, Scheitz JF, Ringleb P, Goganau I, Kaesmacher J, Bae HJ, Kim DY, Kermer P, Suzuki K, Kimura K, Macha K, Koga M, Wada S, Altersberger V, Salerno A, Palanikumar L, Zini A, Forlivesi S, Kellert L, Wischmann J, Kristoffersen ES, Beharry J, Barber PA, Hong JB, Cereda C, Schlemm E, Yakushiji Y, Poli S, Leker R, Romoli M, Zedde M, Curtze S, Ikenberg B, Uphaus T, Giannandrea D, Portela PC, Veltkamp R, Ranta A, Arnold M, Fischer U, Cha JK, Wu TY, Purrucker JC, Seiffge DJ. Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol 2023; 80:233-243. [PMID: 36807495 PMCID: PMC9857462 DOI: 10.1001/jamaneurol.2022.4782] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [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: 07/22/2022] [Accepted: 10/21/2022] [Indexed: 02/07/2023]
Abstract
Importance International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC). Objective To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion. Design, Setting, and Participants This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021. Exposures Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation. Main Outcomes and Measures The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses. Results Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion. Conclusions and Relevance In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.
Collapse
Affiliation(s)
- Thomas R. Meinel
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Henrik Gensicke
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Jan F. Scheitz
- Department of Neurology, Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research Partner Site Berlin, Germany
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ioana Goganau
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Do Yeon Kim
- Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, South Korea
| | - Pawel Kermer
- Department of Neurology, Friesland Kliniken, Sande, Germany
- Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Kosmas Macha
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valerian Altersberger
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society (HELSAM), University of Oslo, Oslo, Norway
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - P. Alan Barber
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jae Beom Hong
- Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carlo Cereda
- Stroke Center and Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Yusuke Yakushiji
- Department of Neurology Kansai Medical University, Hirakata, Japan
| | - Sven Poli
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sami Curtze
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - David Giannandrea
- Division of Neurology and Stroke Unit, Department of Neurology, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - Pere Cardona Portela
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Klinik für Neurologie, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Marcel Arnold
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Stroke Center, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J. Seiffge
- Stroke Research Center Bern, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | |
Collapse
|
7
|
Escudero-Martínez I, Thorén M, Ringleb P, Nunes AP, Cappellari M, Rand VM, Sobolewski P, Egido J, Toni D, Chen SY, Tsao N, Ahmed N. Cerebral Edema in Patients with severe Hemispheric Syndrome: Incidence, Risk Factors, and Outcomes-Data from SITS-ISTR. J Stroke 2023; 25:101-110. [PMID: 36470246 PMCID: PMC9911855 DOI: 10.5853/jos.2022.01956] [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: 06/14/2022] [Accepted: 08/11/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral edema (CED) in ischemic stroke can worsen prognosis and about 70% of patients who develop severe CED die if treated conservatively. We aimed to describe incidence, risk factors and outcomes of CED in patients with extensive ischemia. METHODS Oservational study based on Safe Implementation of Treatments in Stroke-International Stroke Treatment Registry (2003-2019). Severe hemispheric syndrome (SHS) at baseline and persistent SHS (pSHS) at 24 hours were defined as National Institutes of Health Stroke Score (NIHSS) >15. Outcomes were moderate/severe CED detected by neuroimaging, functional independence (modified Rankin Scale 0-2) and death at 90 days. RESULTS Patients (n=8,560) presented with SHS and developed pSHS at 24 hours; 82.2% received intravenous thrombolysis (IVT), 10.5% IVT+thrombectomy, and 7.3% thrombectomy alone. Median age was 77 and NIHSS 21. Of 7,949 patients with CED data, 3,780 (47.6%) had any CED and 2,297 (28.9%) moderate/severe CED. In the multivariable analysis, age <50 years (relative risk [RR], 1.56), signs of acute infarct (RR, 1.29), hyperdense artery sign (RR, 1.39), blood glucose >128.5 mg/dL (RR, 1.21), and decreased level of consciousness (RR, 1.14) were associated with moderate/severe CED (for all P<0.05). Patients with moderate/severe CED had lower odds to achieve functional Independence (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.23 to 0.55) and higher odds of death at 90 days (aOR, 2.54; 95% CI, 2.14 to 3.02). CONCLUSIONS In patients with extensive ischemia, the most important predictors for moderate/ severe CED were age <50, high blood glucose, signs of acute infarct, hyperdense artery on baseline scans, and decreased level of consciousness. CED was associated with worse functional outcome and a higher risk of death at 3 months.
Collapse
Affiliation(s)
- Irene Escudero-Martínez
- Department of Neurology, University Hospital La FE, Valencia, Spain,Neurovascular Research Laboratory, Biomedicine Institute IBiS, Sevilla, Spain,Correspondence: IreneEscudero-Martínez Stroke Unit, Department of Neurology, University Hospital La Fe, Av. Fernando Abril 106, 46026, Valencia, Spain Tel: +34-96-124-4000 Fax: +34-96-124-6241 E-mail:
| | - Magnus Thorén
- Department of Neurology, Danderyd Hospital, Stockholm, Sweden,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ana Paiva Nunes
- Department of Neurology, Sao Jose Hospital, University Hospital Lisboa, Lisboa, Portugal
| | - Manuel Cappellari
- Department of Neuroscience, Integrate University Hospital, Verona, Italy
| | - Viiu-Marika Rand
- Department of Neurology, North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Piotr Sobolewski
- Department of Neurology and Stroke Unit in Sandomierz, Collegium Medicum, Jan Kochanowski University in Kielce, Kielce, Poland
| | - Jose Egido
- Stroke Unit, Department of Neurology, San Carlos Clinic Hospital, Madrid, Spain
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | | | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
8
|
Escudero-Martínez I, Thorén M, Matusevicius M, Cooray C, Zini A, Roffe C, Toni D, Tsivgoulis G, Ringleb P, Wahlgren N, Ahmed N. Association of cholesterol levels with hemorrhagic transformation and cerebral edema after reperfusion therapies. Eur Stroke J 2022; 8:294-300. [PMID: 37021184 PMCID: PMC10069196 DOI: 10.1177/23969873221148229] [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: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 12/30/2022] Open
Abstract
Background: The association between cholesterol levels and cerebral edema (CED) or hemorrhagic transformation (HT) as an expressions of blood-brain barrier (BBB) dysfunction after ischemic stroke is not well established. The aim of this study is to determine the association of total cholesterol (TC) levels with the incidence of HT and CED after reperfusion therapies. Methods: We analyzed SITS Thrombolysis and Thrombectomy Registry data from January 2011 to December 2017. We identified patients with data on TC levels at baseline. TC values were categorized in three groups (reference group ⩾200 mg/dl). The two primary outcomes were any parenchymal hemorrhage (PH) and moderate to severe CED on follow up imaging. Secondary outcomes included death and functional independence (mRS 0–2) at 3 months. Multivariable logistic regression analysis adjusted for baseline factors including statin pretreatment was used to assess the association between TC levels and outcomes. Results: Of 35,314 patients with available information on TC levels at baseline, 3372 (9.5%) presented with TC levels ⩽130 mg/dl, 8203 (23.2%) with TC 130–200 mg/dl and 23,739 (67.3%) with TC ⩾ 200 mg/dl. In the adjusted analyses, TC level as continuous variable was inversely associated with moderate to severe CED (OR 0.99, 95% CI 0.99–1.00, p = 0.025) and as categorical variable lower TC levels were associated with a higher risk of moderate to severe CED (aOR 1.24, 95% CI 1.10–1.40, p = 0.003). TC levels were not associated with any PH, functional independence, and mortality at 3 months. Conclusions: Our findings indicate an independent association between low levels of TC and higher odds of moderate/severe CED. Further studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Irene Escudero-Martínez
- Department of Neurology, Hospital Universitari i Poltècnic La Fe, Valencia, Spain
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Magnus Thorén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital, Stockholm, Sweden
| | - Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Charith Cooray
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Christine Roffe
- Stroke Research in Stoke, Faculty of Medicine & Health Sciences, Keele University, Staffordshire, UK
| | - Danilo Toni
- Neurology Department, University La Sapienza Rome, Rome, Italy
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Peter Ringleb
- Neurology Department, University Hospital Heidelberg, Heidelberg, Germany
| | - Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
9
|
Fukuda-doi M, Koga M, Thomalla G, Jensen M, Inoue M, Yoshimura S, Miwa K, Gerloff CP, Davis S, Donnan GA, Ma H, Hacke W, Ringleb P, Wu O, Schwamm LH, Warach SJ, Boutitie F, Toyoda K. Abstract WMP10: Sex Difference In Imaging-based Intravenous Thrombolysisfor Ischemic Stroke With Unknown Onset Time: A Pooled Analysis Of Clinical Trials. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wmp10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Our prior meta-analysis reported that imaging-based intravenous thrombolysis (IVT) was safe and effective for patients who have had a stroke with an unknown onset time. The aim of this study is to investigate whether sex differences exist in clinical outcomes among this population.
Methods:
This is a pooled analysis of individual patient-level data acquired from the EOS project, a meta-analysis of clinical trials (PROSPERO, CRD42020166903). Patients treated with imaging-based IVT for stroke with an unknown time of onset were included. The primary outcome was a favorable functional outcome (mRS 0-1) at 90 days. Secondary outcomes were mRS shift towards a better functional outcome and death within 90 days. Sex differences were investigated using mixed-effect logistic or ordinal regression models adjusted for covariates, considering potential heterogeneity across trials.
Results:
Among 509 patients treated with imaging-based IVT, 204 (40.1%) were women. Compared to men, women were older (70
±
12 vs. 67
±
13, p=0.003), more frequently had atrial fibrillation (27.6% vs. 17.2%, p=0.005), and were taking antiplatelets prior to the onset (45.5% vs. 36.4%, p=0.045). Baseline NIHSS score was higher (8.0 (IQR 5-15) vs.6 (4-11), p<0.001), and hours from last-known-well to treatment were longer (11.2 (9.3-12.9) vs. 10.3 (8.1-11.9), p<0.001) in women than men. Favorable outcomes occurred in 80 (40.6%) women and in 150 (49.7%) men (p=0.047). Among women, 19 (9.6%) patients died, compared with 15 (5.0%) patients in men (p=0.042). After multivariate adjustment, female sex was not significantly associated with favorable functional outcome (adjusted odds ratio (OR) 1.01[95% confidential intervals (CI) 0.66-1.54]; p=0.97) nor death (adjusted OR 1.28 [95%CI 0.59-2.76]; p=0.59). Female sex was not associated with a significant shift towards the better functional outcome (common OR 1.07 [95%CI 0.77-1.49]; p=0.70).
Conclusions:
Pooled data from clinical trials show that in univariate analysis, women had numerically less good functional outcomes following imaging-based IVT among ischemic stroke patients with unknown onset time. However, this sex difference can be explained by higher age and more severe clinical status in women at stroke onset.
Collapse
Affiliation(s)
| | | | | | | | - Manabu Inoue
- Natl Cerebral and Cardiovascular Ctr, Suita, Japan
| | | | - Kaori Miwa
- Natl Cerebral and Cardiovascular Ctr, Suita, Japan
| | | | | | | | - Henry Ma
- MONASH HEALTH, Clayton, Australia
| | - Werner Hacke
- RUPRECHT KARLS UNIV HEIDELBERG, Heidelberg, Germany
| | | | - Ona Wu
- Massachusetts General Hosp, Boston, MA
| | | | | | | | | | | |
Collapse
|
10
|
Bohmann FO, Gruber K, Kurka N, Willems LM, Herrmann E, du Mesnil de Rochemont R, Scholz P, Rai H, Zickler P, Ertl M, Berlis A, Poli S, Mengel A, Ringleb P, Nagel S, Pfaff J, Wollenweber FA, Kellert L, Herzberg M, Koehler L, Haeusler KG, Alegiani A, Schubert C, Brekenfeld C, Doppler CEJ, Onur ÖA, Kabbasch C, Manser T, Steinmetz H, Pfeilschifter W. Simulation-based training improves process times in acute stroke care (STREAM). Eur J Neurol 2021; 29:138-148. [PMID: 34478596 DOI: 10.1111/ene.15093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The objective of the STREAM Trial was to evaluate the effect of simulation training on process times in acute stroke care. METHODS The multicenter prospective interventional STREAM Trial was conducted between 10/2017 and 04/2019 at seven tertiary care neurocenters in Germany with a pre- and post-interventional observation phase. We recorded patient characteristics, acute stroke care process times, stroke team composition and simulation experience for consecutive direct-to-center patients receiving intravenous thrombolysis (IVT) and/or endovascular therapy (EVT). The intervention consisted of a composite intervention centered around stroke-specific in situ simulation training. Primary outcome measure was the 'door-to-needle' time (DTN) for IVT. Secondary outcome measures included process times of EVT and measures taken to streamline the pre-existing treatment algorithm. RESULTS The effect of the STREAM intervention on the process times of all acute stroke operations was neutral. However, secondary analyses showed a DTN reduction of 5 min from 38 min pre-intervention (interquartile range [IQR] 25-43 min) to 33 min (IQR 23-39 min, p = 0.03) post-intervention achieved by simulation-experienced stroke teams. Concerning EVT, we found significantly shorter door-to-groin times in patients who were treated by teams with simulation experience as compared to simulation-naive teams in the post-interventional phase (-21 min, simulation-naive: 95 min, IQR 69-111 vs. simulation-experienced: 74 min, IQR 51-92, p = 0.04). CONCLUSION An intervention combining workflow refinement and simulation-based stroke team training has the potential to improve process times in acute stroke care.
Collapse
Affiliation(s)
- Ferdinand O Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Katharina Gruber
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Natalia Kurka
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Laurent M Willems
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Faculty of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt am Main, Germany
| | | | - Peter Scholz
- NICU Nursing Staff, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Heike Rai
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Philipp Zickler
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany
| | - Michael Ertl
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Department for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Frank A Wollenweber
- Department of Neurology, Ludwig Maximilians-University Munich, Munich, Germany.,Department of Neurology, Helios-HSK Wiesbaden, Wiesbaden, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians-University Munich, Munich, Germany
| | - Moriz Herzberg
- Department for Diagnostic and Interventional Neuroradiology, Ludwig Maximilians-University Munich, Munich, Germany.,Department of Diagnostic and Interventional Radiology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Luzie Koehler
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | | | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Charlotte Schubert
- Department of Neurology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christopher E J Doppler
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Özgür A Onur
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Tanja Manser
- School of Applied Psychology, FHNW University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland
| | - Helmuth Steinmetz
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany
| | | |
Collapse
|
11
|
Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I. [PMID: 34414303 DOI: 10.1177/23969873211026990] [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: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 11/16/2022] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
Collapse
Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
| |
Collapse
|
12
|
Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I-XLVII. [PMID: 34414302 DOI: 10.1177/23969873211012121] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [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: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 01/01/2023] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
Collapse
Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
| |
Collapse
|
13
|
Fisch U, von Felten S, Wiencierz A, Jansen O, Howard G, Hendrikse J, Halliday A, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Becquemin JP, Algra A, Rothwell P, Ringleb P, Mas JL, Brown M, Brott T, Bonati L. Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
14
|
Fisch U, von Felten S, Wiencierz A, Jansen O, Howard G, Hendrikse J, Halliday A, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Becquemin JP, Algra A, Rothwell P, Ringleb P, Mas JL, Brown MM, Brott TG, Bonati LH. Editor's Choice - Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2021; 61:881-887. [PMID: 33827781 DOI: 10.1016/j.ejvs.2021.02.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/17/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed. METHODS The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation. RESULTS A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019). CONCLUSION Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.
Collapse
Affiliation(s)
- Urs Fisch
- Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland
| | - Stefanie von Felten
- Clinical Trial Unit, Department of Clinical Research, University of Basel, Basel, Switzerland; Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Andrea Wiencierz
- Clinical Trial Unit, Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alison Halliday
- Nuffield Department of Surgery University of Oxford, Oxford, UK
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery-Vascular Centre, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
| | - Richard Bulbulia
- Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Jean-Pierre Becquemin
- Vascular Institute of Paris East, Hôspital Paul D Egine, Champigny-sur-Marne, France
| | - Ale Algra
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands; Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and University of Oxford, Oxford, UK
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg Medical School, Heidelberg, Germany
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Leo H Bonati
- Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.
| | | |
Collapse
|
15
|
Thomalla G, Boutitie F, Ma H, Koga M, Ringleb P, Schwamm LH, Wu O, Bendszus M, Bladin CF, Campbell BCV, Cheng B, Churilov L, Ebinger M, Endres M, Fiebach JB, Fukuda-Doi M, Inoue M, Kleinig TJ, Latour LL, Lemmens R, Levi CR, Leys D, Miwa K, Molina CA, Muir KW, Nighoghossian N, Parsons MW, Pedraza S, Schellinger PD, Schwab S, Simonsen CZ, Song SS, Thijs V, Toni D, Hsu CY, Wahlgren N, Yamamoto H, Yassi N, Yoshimura S, Warach S, Hacke W, Toyoda K, Donnan GA, Davis SM, Gerloff C. Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data. Lancet 2020; 396:1574-1584. [PMID: 33176180 PMCID: PMC7734592 DOI: 10.1016/s0140-6736(20)32163-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/03/2020] [Accepted: 10/12/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patients who have had a stroke with unknown time of onset have been previously excluded from thrombolysis. We aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers. METHODS We did a systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020. Randomised trials of intravenous alteplase versus standard of care or placebo in adults with stroke with unknown time of onset with perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch were eligible. The primary outcome was favourable functional outcome (score of 0-1 on the modified Rankin Scale [mRS]) at 90 days indicating no disability using an unconditional mixed-effect logistic-regression model fitted to estimate the treatment effect. Secondary outcomes were mRS shift towards a better functional outcome and independent outcome (mRS 0-2) at 90 days. Safety outcomes included death, severe disability or death (mRS score 4-6), and symptomatic intracranial haemorrhage. This study is registered with PROSPERO, CRD42020166903. FINDINGS Of 249 identified abstracts, four trials met our eligibility criteria for inclusion: WAKE-UP, EXTEND, THAWS, and ECASS-4. The four trials provided individual patient data for 843 individuals, of whom 429 (51%) were assigned to alteplase and 414 (49%) to placebo or standard care. A favourable outcome occurred in 199 (47%) of 420 patients with alteplase and in 160 (39%) of 409 patients among controls (adjusted odds ratio [OR] 1·49 [95% CI 1·10-2·03]; p=0·011), with low heterogeneity across studies (I2=27%). Alteplase was associated with a significant shift towards better functional outcome (adjusted common OR 1·38 [95% CI 1·05-1·80]; p=0·019), and a higher odds of independent outcome (adjusted OR 1·50 [1·06-2·12]; p=0·022). In the alteplase group, 90 (21%) patients were severely disabled or died (mRS score 4-6), compared with 102 (25%) patients in the control group (adjusted OR 0·76 [0·52-1·11]; p=0·15). 27 (6%) patients died in the alteplase group and 14 (3%) patients died among controls (adjusted OR 2·06 [1·03-4·09]; p=0·040). The prevalence of symptomatic intracranial haemorrhage was higher in the alteplase group than among controls (11 [3%] vs two [<1%], adjusted OR 5·58 [1·22-25·50]; p=0·024). INTERPRETATION In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death. FUNDING None.
Collapse
Affiliation(s)
- Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France; Université Lyon 1, Villeurbanne, France; Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Christopher F Bladin
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Bruce C V Campbell
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Leonid Churilov
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik für Neurologie Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany; German Centre of Cardiovascular Research, Berlin, Germany; German Center of Neurodegenerative Diseases, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Lawrence L Latour
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium; VIB Center for Brain and Disease Research Leuven, Belgium; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Christopher R Levi
- The Department of Neurology, Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Didier Leys
- Université de Lille, Inserm U1171, Lille, France
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CarMeN Laboratory, INSERM U1060/INRA 1397, Lyon, France
| | - Mark W Parsons
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnòstic per la Imatge, Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Peter D Schellinger
- Universitätsklinik für Neurologie, Mühlenkreiskliniken, Johannes Wesling Klinikum Minden, Universitätsklinikum der Ruhr-Universität Bochum, Minden, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Shlee S Song
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Danilo Toni
- Department of Human Neurosciences, University of Rome "La Sapienza", Rome, Italy
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nawaf Yassi
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Steven Warach
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
16
|
Cooray C, Karlinski M, Kobayashi A, Ringleb P, Kõrv J, Macleod MJ, Dixit A, Azevedo E, Bladin C, Ahmed N. Safety and early outcomes after intravenous thrombolysis in acute ischemic stroke patients with prestroke disability. Int J Stroke 2020; 16:710-718. [PMID: 32878588 DOI: 10.1177/1747493020954605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are limited data on intravenous thrombolysis treatment in ischemic stroke patients with prestroke disability. AIM We aimed to evaluate safety and outcomes of intravenous thrombolysis treatment in stroke patients with prestroke disability. METHODS We analyzed 88,094 patients treated with intravenous thrombolysis, recorded in the Safe Implementation of Treatments in Stroke (SITS) International Thrombolysis Register between January 2003 and December 2017, with available NIHSS data at stroke-onset and after 24 h. Of them, 4566 patients (5.2%) had prestroke disability, defined as a modified Rankin Scale score of 3-5. Safety outcome measures included Symptomatic Intracerebral Hemorrhage, any type of parenchymal hematoma on 24 h imaging scans irrespective of clinical symptoms, and death within seven days. Early outcome measures were 24-h NIHSS improvement (≥4 from baseline to 24 h). RESULTS Patients with prestroke disability were older, had more severe strokes, and more comorbidities than patients without prestroke disability. When comparing patients with prestroke disability with patients without prestroke disability, there was however no significant increase in adjusted odds for symptomatic intracerebral hemorrhage (adjusted odds ratio 0.83 (95% CI 0.60-1.15) (absolute difference in proportion 1.17% vs. 1.27%)) or for parenchymal hemorrhage (adjusted odds ratio 0.96 (0.83-1.11) (7.51% vs. 6.34%)). The prestroke disability group had a significantly lower-adjusted odds ratio for a 24-h NIHSS improvement (adjusted odds ratio 0.79 (0.73-0.85) (45.95% vs. 48.45%)) and a higher adjusted odds ratio for seven-day mortality (aOR 1.40 (1.21-1.61) (10.40% vs. 4.93%)). CONCLUSIONS Intravenous thrombolysis in acute ischemic stroke patients with prestroke disability was not associated with an increased risk of symptomatic intracerebral hemorrhage or parenchymal hemorrhage. Prestroke disability was however associated with a higher risk of early mortality compared to patients without prestroke disability.
Collapse
Affiliation(s)
- Charith Cooray
- Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden.,Department of Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Michal Karlinski
- Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Adam Kobayashi
- Department of Neurology, Interventional Stroke Treatment Center, Center for Treatment of Multiple Sclerosis, Faculty of Medical and Health Sciences, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Mary J Macleod
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
| | - Anand Dixit
- University of Newcastle upon Tyne and Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,0Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Christopher Bladin
- 1Public Health Group, Stroke Division, Florey Institute of Neuroscience and Mental Health, the University of Melbourne, Australia
| | - Niaz Ahmed
- Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
17
|
Yu WM, Abdul-Rahim AH, Cameron AC, Kõrv J, Sevcik P, Toni D, Lees KR, Wahlgren N, Ahmed N, Caso V, Roffe C, Kobayashi A, Tsivgoulis G, Toni D, Ford G, Lees K, Ringleb P. The Incidence and Associated Factors of Early Neurological Deterioration After Thrombolysis. Stroke 2020; 51:2705-2714. [DOI: 10.1161/strokeaha.119.028287] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background and purpose:
Early neurological deterioration (END) after stroke onset may predict severe outcomes. Estimated rates of END after intravenous thrombolysis among small patient samples have been reported up to 29.8%. We studied the incidence and factors associated with END among patients following intravenous thrombolysis.
Methods:
We analyzed SITS-International Stroke Thrombolysis registry patients with known outcomes enrolled in 2010 to 2017. END was defined as an increase in National Institutes of Health Stroke Scale score ≥4 or death within 24 hours from baseline National Institutes of Health Stroke Scale. We determined the incidence of END and used logistic regression models to inspect its associated factors. We adjusted for variables found significant in univariate analyses (
P
<0.05). Main outcomes were incidence of END, associated predictors of END, ordinal day-90 mRS, and day-90 mortality.
Results:
We excluded 53 539 patients and included 50 726 patients. The incidence of END was 3415/50 726 (6.7% [95% CI, 6.5%–7.0%]). Factors independently associated with END on multivariate analysis were intracerebral hemorrhage (OR, 3.23 [95% CI, 2.96–3.54],
P
<0.001), large vessel disease (LVD) with carotid stenosis (OR, 2.97 [95% CI, 2.45–3.61],
P
<0.001), other LVD (OR, 2.41 [95% CI, 2.03–2.88],
P
<0.001), and ischemic stroke versus transient ischemic attack (TIA)/stroke mimics (OR, 16.14 [95% CI, 3.99–65.3],
P
<0.001). END was associated with worse outcome on ordinal mRS: adjusted OR 2.48 (95% CI, 2.39–2.57,
P
<0.001) by day-90 compared with no END. The adjusted OR for day-90 mortality was 9.70 (95% CI, 8.36–11.26,
P
<0.001).
Conclusions:
The routinely observed rate of END reflected by real-world data is low, but END greatly increases risk of disability and mortality. Readily identifiable factors predict END and may help with understanding causal mechanisms to assist prevention of END.
Collapse
Affiliation(s)
- Wai M. Yu
- Institute of Cardiovascular and Medical Sciences (W.M.Y., A.C.C.), University of Glasgow, United Kingdom
| | - Azmil H. Abdul-Rahim
- Institute of Neuroscience and Psychology (A.H.A.-R.), University of Glasgow, United Kingdom
| | - Alan C. Cameron
- Institute of Cardiovascular and Medical Sciences (W.M.Y., A.C.C.), University of Glasgow, United Kingdom
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Estonia (J.K.)
| | - Petr Sevcik
- Department of Neurology, Faculty of Medicine in Pilsen-Charles University (P.S.)
- Department of Neurology-University Hospital Pilsen, Plzen, Czech Republic (P.S.)
| | - Danilo Toni
- Department of Human Neurosciences, University La Sapienza, Rome, Italy (D.T.)
| | - Kennedy R. Lees
- School of Medicine, Dentistry and Nursing (K.R.L.), University of Glasgow, United Kingdom
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Fuhrer H, Schönenberger S, Niesen WD, Seide S, Meyne J, Gerner ST, Vollmuth C, Beck C, Meckel S, Schocke M, Wodarg F, Huttner HB, Möhlenbruch MA, Kieser M, Ringleb P, Neugebauer H. Correction to: Endovascular stroke treatment’s impact on malignant type of edema (ESTIMATE). J Neurol 2020; 267:2481. [DOI: 10.1007/s00415-020-09828-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
19
|
Ungerer M, Begli NH, Heyse M, Purrucker J, Regula J, Berberich A, Ciolli L, Nagel S, Ringleb P, Gumbinger C. Patient profiles contribute to differences in quality metrics of stroke centers. NSJ 2020; 25:292-300. [PMID: 33130810 PMCID: PMC8015612 DOI: 10.17712/nsj.2020.4.20190100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives: To examine this association by comparing patient profiles in 2 closely affiliated hospitals and by examining their association with quality metrics. Methods: We performed a retrospective cohort study comparing a university level comprehensive stroke centers (CSC) with its teaching hospital and local stroke unit (LSU) using routinely collected quality assurance data over a 2 year period. Both hospitals were closely affiliated, shared important resources and medical staff rotated amongst both hospitals. We compared patient profiles as well as internationally recognized quality metrics and examined the association of profiles with quality metrics. Results: A total of 2,462 patients were treated in the CSC and 726 in the LSU. The LSU had a longer door-to-image and door-to-needle times. Rate of systemic thrombolysis was lower in the LSU. Patient profiles differed significantly and were associated with door-to-image and door-to-needle times as well as intravenous thrombolysis rates, even when adjusted for stroke service level. The diagnostic procedures for stroke work-up were similar. Discharge management differed strongly. Conclusion: Although LSUs and CSCs are the primary care providers in their respective regions, differences in patient profiles may contribute to differences in performance parameters. Adjusting for patient profiles may improve the comparability of the quality of stroke care provided by hospitals belonging to different stroke service levels.
Collapse
Affiliation(s)
- Matthias Ungerer
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Nima Haji Begli
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Miriam Heyse
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Jan Purrucker
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Jens Regula
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Anne Berberich
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Ludovico Ciolli
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Simon Nagel
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Peter Ringleb
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| | - Christoph Gumbinger
- From the Department of Neurology (Ungerer, Begli, Heyse, Purrucker, Regula, Berberich, Nagel, Ringleb, Gumbinger), University Hospital Heidelberg, Heidelberg; from the Department of Neurology (Purrucker, Regula), GRN-Klinik Sinsheim, Sinsheim, Germany; and from the Stroke Unit, Neurology Unit, Department of Neuroscience (Ciolli), Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Modena, Italy.
| |
Collapse
|
20
|
Westphal LP, Widmer R, Held U, Steigmiller K, Hametner C, Ringleb P, Curtze S, Martinez-Majander N, Tiainen M, Nolte CH, Scheitz JF, Erdur H, Polymeris AA, Traenka C, Eskandari A, Michel P, Heldner MR, Arnold M, Zini A, Vandelli L, Coutinho JM, Groot AE, Padjen V, Jovanovic DR, Bejot Y, Brenière C, Turc G, Seners P, Pezzini A, Magoni M, Leys D, Gilliot S, Scherrer MJ, Kägi G, Luft AR, Gensicke H, Nederkoorn P, Tatlisumak T, Engelter ST, Wegener S. Association of prestroke metformin use, stroke severity, and thrombolysis outcome. Neurology 2020; 95:e362-e373. [PMID: 32601121 DOI: 10.1212/wnl.0000000000009951] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 01/06/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate whether pretreatment with metformin (MET) is associated with less stroke severity and better outcome after IV thrombolysis (IVT), we analyzed a cohort of 1,919 patients with stroke with type 2 diabetes mellitus in a multicenter exploratory analysis. METHODS Data from patients with diabetes and ischemic stroke treated with IVT were collected within the European Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration. We applied propensity score matching (PSM) to obtain balanced baseline characteristics of patients treated with and without MET. RESULTS Of 1,919 patients with stroke with type 2 diabetes who underwent IVT, 757 (39%) had received MET before stroke (MET+), whereas 1,162 (61%) had not (MET-). MET+ patients were younger with a male preponderance. Hypercholesterolemia and pretreatment with statins, antiplatelets, or antihypertensives were more common in the MET+ group. After PSM, the 2 groups were well balanced with respect to demographic and clinical aspects. Stroke severity on admission (NIH Stroke Scale 10.0 ± 6.7 vs 11.3 ± 6.5), 3-month degree of independence on modified Rankin Scale (2 [interquartile range (IQR) 1.0-4.0] vs 3 [IQR 1.0-4.0]), as well as mortality (12.5% vs 18%) were significantly lower in the MET+ group. The frequency of symptomatic intracerebral hemorrhages did not differ between groups. HbA1c levels were well-balanced between the groups. CONCLUSIONS Patients with stroke and diabetes on treatment with MET receiving IVT had less severe strokes on admission and a better functional outcome at 3 months. This suggests a protective effect of MET resulting in less severe strokes as well as beneficial thrombolysis outcome.
Collapse
Affiliation(s)
- Laura P Westphal
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Roni Widmer
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Ulrike Held
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Klaus Steigmiller
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Christian Hametner
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Peter Ringleb
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Sami Curtze
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Nicolas Martinez-Majander
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Marjaana Tiainen
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Christian H Nolte
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Jan F Scheitz
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Hebun Erdur
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Alexandros A Polymeris
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Christopher Traenka
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Ashraf Eskandari
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Patrik Michel
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Mirjam R Heldner
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Marcel Arnold
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Andrea Zini
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Laura Vandelli
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Jonathan M Coutinho
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Adrien E Groot
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Visnja Padjen
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Dejana R Jovanovic
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Yannick Bejot
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Céline Brenière
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Guillaume Turc
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Pierre Seners
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Alessandro Pezzini
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Mauro Magoni
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Didier Leys
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Sixtine Gilliot
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Michael J Scherrer
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Georg Kägi
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Andreas R Luft
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Henrik Gensicke
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Paul Nederkoorn
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Turgut Tatlisumak
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Stefan T Engelter
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - Susanne Wegener
- From the Department of Neurology (L.P.W., R.W., A.R.L., S.W.), University Hospital Zurich; Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics (U.H., K.S.), University of Zurich, Switzerland; Department of Neurology (C.H., P.R.), University Hospital Heidelberg, Germany; Department of Neurology (S.C., N.M.-M., M.T.), University of Helsinki and Helsinki University Hospital, Finland; Department of Neurology and Center for Stroke Research (C.H.N., J.F.S., H.E.), Charité University Hospital, Berlin, Germany; Stroke Center and Neurology (A.A.P., C.T., H.G., S.T.E.), University Hospital Basel and University Basel; Department of Neurology (A.E., P.M.), University Hospital Lausanne; Department of Neurology (M.R.H., M.A.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Stroke Center (A.Z.), IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital; Stroke Unit (L.V.), Department of Neuroscience, S'Agostino-Estense Hospital, Modena University Hospital, Italy; Department of Neurology (J.M.C., A.E.G., P.N.), Amsterdam University Medical Centers (AUMC), Location AMC, University of Amsterdam, the Netherlands; Neurology Clinic Belgrade (V.P., D.R.J.), Clinical Centre of Serbia; Medical Faculty (D.R.J.), University of Belgrade, Serbia; Department of Neurology (Y.B., C.B.), University Hospital of Dijon, University of Burgundy; Department of Neurology (G.T., P.S.), Sainte-Anne Hospital, Paris, France; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia; Stroke Unit (M.M.), ASST Spedali Civili, Brescia, Italy; Department of Neurology (D.L., S.G.), University Hospital of Lille, France; Department of Neurology (M.J.S., G.K.), St. Gallen Cantonal Hospital, Switzerland; Department of Neurology (T.T.), Sahlgrenska University Hospital; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland.
| | | |
Collapse
|
21
|
Ungerer MN, Ringleb P, Reuter B, Stock C, Ippen F, Hyrenbach S, Bruder I, Martus P, Gumbinger C, Schabet M, Schoser K, Daffertshofer M, Neumaier S, Sorge R, Drewitz E, Hyrenbach S. Stroke unit admission is associated with better outcome and lower mortality in patients with intracerebral hemorrhage. Eur J Neurol 2020; 27:825-832. [DOI: 10.1111/ene.14164] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 02/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- M. N. Ungerer
- Department of Neurology University Hospital Heidelberg Heidelberg
| | - P. Ringleb
- Department of Neurology University Hospital Heidelberg Heidelberg
| | | | - C. Stock
- Institute of Medical Biometry and Informatics (IMBI) University of Heidelberg Heidelberg
| | - F. Ippen
- Department of Neurology University Hospital Heidelberg Heidelberg
| | - S. Hyrenbach
- Qualitätssicherung im Gesundheitswesen Baden‐Wuerttemberg (GeQiK Baden‐Wuerttemberg) Stuttgart
| | - I. Bruder
- Qualitätssicherung im Gesundheitswesen Baden‐Wuerttemberg (GeQiK Baden‐Wuerttemberg) Stuttgart
| | - P Martus
- Institute for Clinical Epidemiology and Applied Biometry University of Tuebingen Tuebingen Germany
| | - C. Gumbinger
- Department of Neurology University Hospital Heidelberg Heidelberg
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Berberich A, Schneider C, Herweh C, Hielscher T, Reiff T, Bendszus M, Gumbinger C, Ringleb P. Risk factors associated with progressive lacunar strokes and benefit from dual antiplatelet therapy. Eur J Neurol 2020; 27:817-824. [PMID: 31994783 DOI: 10.1111/ene.14159] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Early neurological deterioration (END) occurs in 20%-30% of patients with lacunar stroke and challenges their clinical management. This retrospective cohort study analyzed clinical and neuroimaging risk factors predicting the occurrence of END, the functional outcome after END and potential benefit from dual antiplatelet therapy (DAPT) in patients with lacunar strokes. METHODS Factors associated with END and benefit from DAPT were retrospectively analyzed in 308 patients with lacunar stroke symptoms and detected lacunar infarction by magnetic resonance imaging. END was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale (NIHSS) points, ≥2 NIHSS points for limb paresis or documented deterioration within 5 days after admission. Patients were treated with DAPT according to in-house standards. The primary efficacy end-point for functional outcome was fulfilled if NIHSS at discharge improved after END at least to the score at admission. RESULTS Male gender [odds ratio (OR) 2.08; 95% confidence interval (CI) 1.09-4.00], higher age (OR = 1.65 per 10 years; 95% CI 1.18-2.31), motor paresis (OR = 18.89, 95% CI 4.66-76.57) and infarction of the internal capsule or basal ganglia (OR = 3.58, 95% CI 1.26-10.14) were associated with an increased risk for END. A larger diameter of infarction (OR = 0.85, 95% CI 0.76-0.95), more microangiopathic lesions (OR = 0.75, 95% CI 0.57-0.99) and pontine localization (OR = 0.29, 95% CI 0.12-0.65) were factors associated with unfavorable functional outcome after END occurred. Localization in the internal capsule or basal ganglia was identified as a significant predictive factor for a benefit from DAPT after END. CONCLUSIONS Identified clinical and neuroimaging factors predicting END occurrence, functional outcome after END and potential benefit from DAPT might improve the clinical management of patients with lacunar strokes.
Collapse
Affiliation(s)
- A Berberich
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Schneider
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - T Hielscher
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - T Reiff
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - C Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
23
|
Cheng B, Boutitie F, Nickel A, Wouters A, Cho TH, Ebinger M, Endres M, Fiebach JB, Fiehler J, Galinovic I, Puig J, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G, Golsari A, Alegiani A, Beck C, Choe CU, Voget D, Hoppe J, Schröder J, Rozanski M, Nave AH, Wollboldt C, van Sloten I, Göhler J, Herm J, Jungehülsing J, Lückl J, Kröber JM, Schurig J, Koehler L, Schlemm L, Knops M, Roennefarth M, Ipsen N, Harmel P, Bathe-Peters R, Fleischmann R, Ganeshan R, Geran R, Hellwig S, Schmidt S, Tütüncü S, Krause T, Gramse V, Röther J, Michels P, Michalski D, Pelz J, Schulz A, Hobohm C, Weise C, Weise G, Orthgieß J, Pomrehn K, Wegscheider M, Mueller AK, Hennerici M, Griebe M, Alonso A, Filipov A, Marzina A, Anders B, Bähr C, Hoyer C, Schwarzbach C, Weber C, Hornberger E, Pledl HW, Klockziem M, Stuermlinger M, Wittayer M, Wolf M, Meyer N, Eisele P, Steinert S, Sauer T, Held V, Ringleb P, Nagel S, Veltkamp R, Schwarting S, Schwarz A, Gumbinger C, Hametner C, Amiri H, Purrucker J, Ciatipis M, Menn O, Mundiyanapurath S, Schieber S, Kessler T, Reiff T, Panitz V, Singer O, Foerch C, Lauer A, Männer A, Seiler A, Guerzoglu D, Schäfer JH, Filipski K, Lorenz M, Kurka N, Zeiner P, Pfeilschifter W, Dziewas R, Minnerup J, Albiker C, Ritter M, Seidel M, Dittrich R, Kallmünzer B, Bobinger T, Madzar D, Stark D, Sembill J, Macha K, Winder K, Breuer L, Koehrmann M, Spruegel M, Gerner S, Kraft P, Mackenrodt D, Kleinschnitz C, Elhfnawy A, Heinen F, Gunreben I, Poli S, Ziemann U, Gaenslen A, Schlak D, Haertig F, Russo F, Richter H, Ebner M, Ribitsch M, Wolf M, Weimar C, Zegarac V, Chen HC, Althaus K, Neugebauer H, Jüttler E, Meier J, Stösser S, Puetz V, Bodechtel U, Ostergaard L, Møller A, Damgaard D, Dupont KH, Poulsen M, Hjort N, de Morales NR, von Weitzel P, Harbo T, Marstrand J, Hansen A, Christensen H, Aegidius K, Jeppesen L, Meden P, Rosenbaum S, Iversen H, Hansen J, Michelsen L, Truelsen T, Modrau B, Vestergaard K, Oppel L, Sygehus A, Aalborg S, Swinnen B, Smets I, Demeestere J, Dobbels L, Brouns R, De Smedt A, DeKeyser J, Yperzeele L, Van Hooff RJ, Peeters A, Dusart A, Etexberria A, Hanseeuw B, London F, Leempoel J, Hohenbichler K, Younan N, Maqueda V, Laloux P, De Coene B, De Maeseneire C, Turine G, Vandermeeren Y, De Klippel N, Willems C, de Hollander I, Soors P, Hermans S, Hemelsoet D, Desfontaines P, Vanacker P, Rutgers M, Druart C, Peeters D, Bruneel B, Vancaester E, Vanhee F, Meersman G, Bourgeois P, Vanderdonckt P, Benoit A, Derex L, Mechthouff L, Berhoune N, Ritzenthaler T, Amarenco P, Hobeanu C, Gancedo EM, Calvet D, Ladoux A, Machet A, Lamy C, Mellerio C, Oppenheim C, Rodriguez-Regent C, Bodiguel E, Turc G, Birchenall J, Legrand L, Morin L, Edjali-Goujon M, Naggara O, Raphaelle S, Godon-Hardy S, Domigo V, Guiraud V, Samson Y, Leger A, Rosso C, Baronnet-Chauvet F, Crozier S, Deltour S, Yger M, Sibon I, Renou P, Sagnier S, Zuber M, Tamazyan R, Rodier G, Morel N, Felix S, Vadot W, Wolff V, Aniculaesei A, Yalo B, Bindila D, Quenardelle V, Blanc-Lasserre K, Landrault E, Breynaert L, Cakmak S, Peysson S, Viguier A, Lebely C, Raposo N, Vallet AE, Vallet P, Brugirard S, Cheripelli B, Kalladka D, Moreton F, Dani K, Tawil SE, Ramachandran S, Huang X, Warburton E, Evans N, Perry R, Patel B, Cloud G, Pereira A, Moynihan B, Lovelock C, Choy L, Khan U, Roffe C, Tyrell P, Smith C, Dixit A, Louw S, Broughton D, Shetty A, Appleton J, Sprigg N, Acosta BR, van Eendenburg C, Leal JS, Mar Castellanos Rodrigo MD, Izaga MT, Guillamon OB, Arenillas J, Calleja A, Cortijo E, Mulero P, de la Ossa NP, Garrido A, Martinez A, Esperón CG, Guerrero C, Carrera D, Vilas D, Lopez-cancio E, Palomeras E, Lucente G, Gomis M, Isern I, Becerra JL, Vicente JH, Sánchez J, Dorado L, Grau L, Ispierto L, Prats L, Almendrote M, Hernández M, Jimenez M, Sánchez ML, Torne MM, Presas S, Ustrell X, Pellisé A, Navalpotro I, Luna A, Schonewille W, Nederkoorn P, Majoie C, van den Berg L, van den Berg S, Zonneveld T, Remmers M, Fazekas F, Pichler A, Fandler S, Gattringer T, Mutzenbach J, Weber J, Höfner E, Kohlfürst H, Weinstich K, Kellert L, Bayer-Karpinska A, Opherk C, Wollenweber F, Klein M, Neumann- Haefelin T, Pierskalla A, Harloff A, Bardutzky J, Buggle F, von Schrader J, Kollmar R, Schill J, Löbbe AM, Moulin T, Bouamra B, Bonnet L, Touzé E, Bonnet AL, Touze E, Cogez J, Li L, Guettier S, Kar A, Sivagnanaratham A, Geraghty O, Bojaryn U, Nallasivan A, Gonzales MB, Rodríguez-Yáñez M, Tembl J, Gorriz D, Oberndorfer S, Prohaska E. Quantitative Signal Intensity in Fluid-Attenuated Inversion Recovery and Treatment Effect in the WAKE-UP Trial. Stroke 2020; 51:209-215. [DOI: 10.1161/strokeaha.119.027390] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase.
Methods—
FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume.
Results—
FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 (
P
=0.169) and shift analysis (
P
=0.086) but reached significance for mRS score of 0 to 2 (
P
=0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI.
Conclusions—
In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.
Collapse
Affiliation(s)
- Bastian Cheng
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Florent Boutitie
- Service de Biostatistique, Hospices Civils de Lyon, France (F.B.)
- Université Lyon 1, Villeurbanne, France (F.B.)
- CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France (F.B.)
| | - Alina Nickel
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anke Wouters
- Department of Neurology, University Hospitals Leuven, Belgium (A.W., R.L.)
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Belgium (A.W., R.L.)
- VIB, Center for Brain and Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium (A.W., R.L.)
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, France (T.-H.C., N.N.)
- Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
- Neurologie der Rehaklinik Medical Park Humboldtmühle, Berlin, Germany (M. Ebinger)
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany (M. Endres)
| | - Jochen B. Fiebach
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image, Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona, Parc Hospitalari Martí i Julià de Salt, Girona, Spain (J.P., S.P.)
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia (V.T.)
- Austin Health, Department of Neurology, VIC, Australia (V.T.)
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (A.W., R.L.)
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Belgium (A.W., R.L.)
- VIB, Center for Brain and Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium (A.W., R.L.)
| | - Keith W. Muir
- Institute of Neuroscience and Psychology, University of Glasgow, United Kingdom (K.W.M.)
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, France (T.-H.C., N.N.)
- Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image, Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona, Parc Hospitalari Martí i Julià de Salt, Girona, Spain (J.P., S.P.)
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.)
| | - Christian Gerloff
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Gumbinger C, Ringleb P, Ippen F, Ungerer M, Reuter B, Bruder I, Daffertshofer M, Stock C. Outcomes of patients with stroke treated with thrombolysis according to prestroke Rankin Scale scores. Neurology 2019; 93:e1834-e1843. [PMID: 31653709 DOI: 10.1212/wnl.0000000000008468] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 06/18/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND It is common practice to withhold IV thrombolysis (IVT) for acute ischemic stroke in patients with preexisting disabilities. To test the hypothesis of an association of IVT and good clinical outcome also in patients with preexisting disabilities without an increase in mortality, we analyzed data from 52,741 patients (15,317 treated with IVT) depending on prestroke Rankin Scale (pRS) score. METHODS We performed an observational study based on a consecutive stroke registry covering 10.8 million inhabitants. The outcome at discharge of patients with stroke admitted in the time window of potential eligibility for IVT (<4.5 hours after stroke onset) was compared between patients treated and those not treated with thrombolysis, stratified by pRS score. Logistic regression analysis was used to estimate adjusted odds ratios (ORs) along with 95% confidence intervals (CIs) for favorable clinical outcome, defined as returning to the baseline pRS score or a score of 0 or 1 and mortality. Sensitivity analyses for subgroups of mildly and severely affected patients with stroke were performed, and the influence of treatment duration was assessed. RESULTS Among included patients, IVT rates were 32% for patients with pRS scores of 0 to 1 and 20% for patients with pRS scores of 2 to 5. IVT in patients with pRS scores of 0 to 4 was associated with a higher chance of returning to the baseline pRS score (or a modified Rankin Scale score of 0/1), with ORs ranging between 1.42 (pRS score 2; 95% CI 1.16-1.73) and 1.73 (pRS score 0; 95% CI 1.61-1). The OR observed in patients with a pRS score of 5 was 0.65 (95% CI 0.25-1.70). Observed associations remained consistent in sensitivity analyses. Subgroup analyses revealed no evidence of bias due to potential floor and ceiling effects. No evidence of elevated in-hospital mortality of patients treated with thrombolysis was observed. CONCLUSIONS Our study suggests that IVT can be effective even in patients with severe preexisting disabilities, provided that they were not bedridden before stroke onset. Withholding IVT on the sole ground of prestroke disabilities may not be justified.
Collapse
Affiliation(s)
- Christoph Gumbinger
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany.
| | - Peter Ringleb
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Franziska Ippen
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Matthias Ungerer
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Björn Reuter
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Ingo Bruder
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Michael Daffertshofer
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | - Christian Stock
- From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany
| | | |
Collapse
|
25
|
Bohmann FO, Kurka N, du Mesnil de Rochemont R, Gruber K, Guenther J, Rostek P, Rai H, Zickler P, Ertl M, Berlis A, Poli S, Mengel A, Ringleb P, Nagel S, Pfaff J, Wollenweber FA, Kellert L, Herzberg M, Koehler L, Haeusler KG, Alegiani A, Schubert C, Brekenfeld C, Doppler CEJ, Onur OA, Kabbasch C, Manser T, Pfeilschifter W. Simulation-Based Training of the Rapid Evaluation and Management of Acute Stroke (STREAM)-A Prospective Single-Arm Multicenter Trial. Front Neurol 2019; 10:969. [PMID: 31572288 PMCID: PMC6749045 DOI: 10.3389/fneur.2019.00969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 08/23/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Acute stroke care delivered by interdisciplinary teams is time-sensitive. Simulation-based team training is a promising tool to improve team performance in medical operations. It has the potential to improve process times, team communication, patient safety, and staff satisfaction. We aim to assess whether a multi-level approach consisting of a stringent workflow revision based on peer-to-peer review and 2–3 one-day in situ simulation trainings can improve acute stroke care processing times in high volume neurocenters within a 6 months period. Methods and Analysis: The trial is being carried out in a pre-test-post-test design at 7 tertiary care university hospital neurocenters in Germany. The intervention is directed at the interdisciplinary multiprofessional stroke teams. Before and after the intervention, process times of all direct-to-center stroke patients receiving IV thrombolysis (IVT) and/or endovascular therapy (EVT) will be recorded. The primary outcome measure will be the “door-to-needle” time of all consecutive stroke patients directly admitted to the neurocenters who receive IVT. Secondary outcome measures will be intervention-related process times of the fraction of patients undergoing EVT and effects on team communication, perceived patient safety, and staff satisfaction via a staff questionnaire. Interventions: We are applying a multi-level intervention in cooperation with three “STREAM multipliers” from each center. First step is a central meeting of the multipliers at the sponsor's institution with the purposes of algorithm review in a peer-to-peer process that is recorded in a protocol and an introduction to the principles of simulation training and debriefing as well as crew resource management and team communication. Thereafter, the multipliers cooperate with the stroke team trainers from the sponsor's institution to plan and execute 2–3 one-day simulation courses in situ in the emergency department and CT room of the trial centers whereupon they receive teaching materials to perpetuate the trainings. Clinical Trial Registration: STREAM is a registered trial at https://clinicaltrials.gov/ct2/show/NCT03228251.
Collapse
Affiliation(s)
| | - Natalia Kurka
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Katharina Gruber
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Peter Rostek
- NICU Nursing Staff, University Hospital Frankfurt, Frankfurt, Germany
| | - Heike Rai
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany
| | - Philipp Zickler
- Department of Neurology and Clinical Neurophysiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Michael Ertl
- Department of Neurology and Clinical Neurophysiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Department for Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology With Focus on Neurovascular Diseases and Neurooncology, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology With Focus on Neurovascular Diseases and Neurooncology, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Lars Kellert
- Department of Neurology, Ludwig Maximilians-University, Munich, Germany
| | - Moriz Herzberg
- Department for Diagnostic and Interventional Neuroradiology, Ludwig Maximilians-University, Munich, Germany
| | - Luzie Koehler
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | - Karl Georg Haeusler
- Centre for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Charlotte Schubert
- Department of Neurology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | | | - Oezguer A Onur
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Tanja Manser
- School of Applied Psychology, FHNW University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland
| | | | | |
Collapse
|
26
|
Bornstein NM, Saver JL, Diener HC, Gorelick PB, Shuaib A, Solberg Y, Devlin T, Leung T, Molina CA, Skoloudik D, Fiksa J, Krieger D, Andersen G, Berrouschot J, Hobohm C, Schneider D, Griewing B, Endres M, Hausler KG, Kimmig H, Ringleb P, Weimar C, Schilling M, Kohrmann M, Hetzel A, Kaps M, Cheung R, Sobolewski P, Nyke W, Czlonkowska A, Stepien A, Waldemar B, Słowik A, Zbigniewem S, Lubiński I, Portela P, Segure T, Marti-Fabregas J, Alonso M, Nunez A, Miguel MB, Campello A, Arenillas J, Marshall N, Chiu D, Shownkeen H, Rymer M, Sen S, Roubec M, Kuliha M, Lakomý C, Tyl D, Kemlink D, Doležal O, Rekova P, Krejčí V, Christensen A, Belhage B, Maschmann C, Kruse Larsen C, Pott F, Christensen H, Marstrand J, Nielsen JK, Meden P, Prytz S, Rosenbaum S, Hedemann Sorensen JC, Stenhoj Meier K, Schmift Ettrup K, Dupont Hougaard K, Von Wietzel P, Stoll A, Schwetlick H, Pradel H, Hemprich A, Schulz A, Frerich B, Hobohm C, Weise C, Michalski D, Schaller F, Schiefke F, Helmrich J, Pelz J, Schnieder M, Schneider M, Matzen P, Langos R, Müller-Duerwald S, Lukhaup S, Bauer U, Kloppig W, Hiermann E, Mucha G, Soda H, Weinhardt R, Mucha T, Ziegler V, Abbushi A, Hotter B, Winter B, Anthofer B, Noack C, Laubisch D, Heldge Schneider G, Jan Jungehulsing G, Mueller H, Dreier J, Fiebach J, Flechsenhar J, Villringer K, Ebinger M, Rozanski M, Vajkoczy P, Klingebiel R, Steinicke R, Pittl S, Hoffmann S, Maul S, Krause T, Liman T, Plath T, Nowe T, Schmidt W, Fritzsch C, Haas C, Will HG, Haußmann-Betz K, Bayat M, Pordzik T, Hug A, Staff CJ, Lichy C, Eggers G, Kloss M, Bendszus M, Herrmann O, Seeberger R, Schwarting S, Rhode S, Rizos T, Hacke W, Frank B, Bozkurt B, Holle D, Mueller D, Koch D, Shanib H, Sudendey J, Brenck J, Busch K, Gartzen K, Gasser T, Hagenacker T, Buerke B, Prigge G, Minnerup J, Albers J, Wermker K, Schwindt W, Kallmünzer RB, Hauer E, Breuer L, Schellinger P, Kollmar R, Sauer R, Schwab S, Struffert T, Funfack A, Stechmann A, Schlaeger A, Laeppchen C, Schuchardt F, Klingler JH, Reis J, Lambeck J, Friedrich M, Laible M, Wellermeyer P, Beck S, Rutsch S, Niesen WD, Tanislav C, Schaaf H, Kerkmann H, Schirotzek I, Allendörfer J, Wolff S, Yuk-Lun Lau A, Yin Yan Chan A, Siu D, Wong EHC, Chu Wong GK, Leung H, Wong LK, Zhu XL, Yan Soo YO, Ting Tse AC, Kit Leung GK, Leung KM, Ngai Hung K, Wai Mei Kwan M, Man Yu Tse M, Tse P, Hon Chan P, Lee R, Shek Kwan Chang R, Yin Yu Pang S, Fong Kwong Hon S, Cheng TS, Lui WM, Wo Mak WW, Sobota A, Wiater B, Loch B, Wolak G, Łabudzka I, Dabal J, Grzesik M, Sledzinska M, Hatalska-Żerebiec R, Szczuchniak W, Gójska A, Nałęcz D, Gasecki D, Kozera G, Dylewicz Ł, Niekra M, Kwarciany M, Chomik P, Skowron P, Kobayashi A, Chabik G, Makowicz G, Bembenek J, Jędrzejewska J, Karlinski M, Czepiel W, Brodacki B, Staszewski J, Kosek J, Jadczak M, Durka-Kęsy M, Kaluzny K, Ziomek M, Fudala M, Sosnowski Z, Ferens A, Szczygieł E, Banaszkiewicz K, Ziomek M, Wnuk M, Szczepańska-Szerej A, Jach E, Maslanko GE, Wojczal J, Luchowski P, Kowalczyk A, Jakubiak J, Kopcewicz J, Gajda M, Wichlinska-Lubinska M, Rodriguez D, Santamarin E, Pagola J, Lorente Guerrero J, Ribo M, Rubiera M, Maisterra O, Pinero S, Catalina Iglesias V, Plans G, Quesada H, Aparicio Caballero MA, Portela PC, De Diego AB, Garay DS, García Rodriguez MR, Martin OA, Braña SC, Garcia J, Hernandez FM, Catala I, Marti-Vilalta JL, Delgado Mederos R, de Quintana SC, Martinez-Ramirez S, Valcarcel Gonzalez J, Masjuan Vallejo J, Diamantopoulus J, Del Alamo M, Poveda PD, Pastor AG, Carballal CF, Diaz F, Garcia Leal R, Juretschke R, Echabe EA, Sanchez JC, Yanez MR, Garcia RS, Muino RL, Rivas SA, Lopez Gonzalez DM, Cuadrado E, Giralt E, Villalba G, Roquer J, Angel O, Jimenez M, Cedeño RR, Salinas R, Lejarreta S, Silva Y, Fraile A, Calleja A, Cepeda Landínez GA, Tellez N, Garcia Bermejo P, Santos PJ, Herranz RF, Hunt P, Browning D, Violette M, Hoddeson R, Rose J, Zhang J, Mazumdar A, Echiverri H, Chow J, Lovick D, Coleman M, Akhtar N, Sugg R, Zanation A, Germanwala A, Senior B, Huang D, Aucutt-Walter N, Kasner S, LeRoux P, von Kummer R, Palesch Y. Sphenopalatine Ganglion Stimulation to Augment Cerebral Blood Flow. Stroke 2019; 50:2108-2117. [DOI: 10.1161/strokeaha.118.024582] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy.
Methods—
In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improvements in device placement occurred, so that analysis of accumulated experience could be conducted to inform a successor trial.
Results—
Among 303 enrolled patients, 253 received at least one active SPG or sham stimulation, constituting the modified intention-to-treat population (153 SPG stimulation and 100 sham control). Age was median 73 years (interquartile range, 64–79), 52.6% were female, deficit severity on the National Institutes of Health Stroke Scale was median 11 (interquartile range, 9–15), and time from last known well median 18.6 hours (interquartile range, 14.5–22.5). For the primary outcome, improved 3-month disability beyond expectations, rates in the SPG versus sham treatment groups were 49.7% versus 40.0%; odds ratio, 1.48 (95% CI, 0.89–2.47);
P
=0.13. A significant treatment interaction with stroke location (cortical versus noncortical) was noted,
P
=0.04. In the 87 patients with confirmed cortical involvement, rates of improvement beyond expectations were 50.0% versus 27.0%; odds ratio, 2.70 (95% CI, 1.08–6.73);
P
=0.03. Similar response patterns were observed for all prespecified secondary efficacy outcomes. No differences in mortality or serious adverse event safety end points were observed.
Conclusions—
SPG stimulation within 24 hours of onset is safe in acute ischemic stroke. SPG stimulation was not shown to statistically significantly improve 3-month disability above expectations, though favorable outcomes were nominally higher with SPG stimulation. Beneficial effects may distinctively be conferred in patients with confirmed cortical involvement. The results of this study need to be confirmed in a larger pivotal study.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03767192.
Collapse
Affiliation(s)
- Natan M. Bornstein
- From the Brain Division, Shaarei Zedek Medical Center, Jerusalem and Tel Aviv Sourasky Medical School, Tel Aviv University (N.M.B.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles CA (J.L.S.)
| | | | - Philip B. Gorelick
- Davee Department of Neurology, Northwestern University, Chicago, IL (P.B.G.)
| | - Ashfaq Shuaib
- Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.)
| | | | - Thomas Devlin
- Department of Neurology, University of Tennessee College of Medicine, Chattanooga (T.D.)
| | - Thomas Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong (T.L.)
| | - Carlos A. Molina
- and Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Barcelona (C.A.M.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Cooray C, Mazya M, Mikulik R, Jurak L, Brozman M, Ringleb P, Dixit A, Toni D, Ahmed N. Safety and Outcome of Intravenous Thrombolysis in Stroke Patients on Prophylactic Doses of Low Molecular Weight Heparins at Stroke Onset. Stroke 2019; 50:1149-1155. [DOI: 10.1161/strokeaha.118.024575] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Charith Cooray
- From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.A.)
| | - Michael Mazya
- From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.A.)
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne’s University Hospital in Brno, Masaryk University, Czech Republic (R.M.)
| | - Lubomir Jurak
- Neurocentre, Regional Hospital Liberec, Czech Republic (L.J.)
| | - Miroslav Brozman
- Faculty Hospital Nitra, Constantine Philosopher University, Slovakia (M.B.)
| | - Peter Ringleb
- Department of Neurology, Heidelberg University Hospital, Germany (P.R.)
| | - Anand Dixit
- University of Newcastle upon Tyne and Newcastle upon Tyne Hospitals NHS Foundation Trust (A.D.)
| | - Danilo Toni
- Emergency Department Stroke Unit, Hospital Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University, Rome, Italy (D.T.)
| | - Niaz Ahmed
- From the Department of Clinical Neurosciences, Karolinska Institutet and Department of Neurology Karolinska University Hospital, Stockholm, Sweden (C.C., M.M., N.A.)
| |
Collapse
|
28
|
Ringleb P, Bendszus M, Bluhmki E, Donnan G, Eschenfelder C, Fatar M, Kessler C, Molina C, Leys D, Muddegowda G, Poli S, Schellinger P, Schwab S, Serena J, Toni D, Wahlgren N, Hacke W. Extending the time window for intravenous thrombolysis in acute ischemic stroke using magnetic resonance imaging-based patient selection. Int J Stroke 2019; 14:483-490. [PMID: 30947642 DOI: 10.1177/1747493019840938] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [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: 11/17/2022]
Abstract
BACKGROUND Intravenous thrombolysis with alteplase within a time window up to 4.5 h is the only approved pharmacological treatment for acute ischemic stroke. We studied whether acute ischemic stroke patients with penumbral tissue identified on magnetic resonance imaging 4.5-9 h after symptom onset benefit from intravenous thrombolysis compared to placebo. METHODS Acute ischemic stroke patients with salvageable brain tissue identified on a magnetic resonance imaging were randomly assigned to receive standard dose alteplase or placebo. The primary end point was disability at 90 days assessed by the modified Rankin scale, which has a range of 0-6 (with 0 indicating no symptoms at all and 6 indicating death). Safety end points included death, symptomatic intracranial hemorrhage, and other serious adverse events. RESULTS The trial was stopped early for slow recruitment after the enrollment of 119 (61 alteplase, 58 placebo) of 264 patients planned. Median time to intravenous thrombolysis was 7 h 42 min. The primary endpoint showed no significant difference in the modified Rankin scale distribution at day 90 (odds ratio alteplase versus placebo, 1.20; 95% CI, 0.63-2.27, P = 0.58). One symptomatic intracranial hemorrhage occurred in the alteplase group. Mortality at 90 days did not differ significantly between the two groups (11.5 and 6.8%, respectively; P = 0.53). CONCLUSIONS Intravenous alteplase administered between 4.5 and 9 h after the onset of symptoms in patients with salvageable tissue did not result in a significant benefit over placebo. (Supported by Boehringer Ingelheim, Germany; ISRCTN 71616222).
Collapse
Affiliation(s)
- Peter Ringleb
- 1 Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- 2 Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Erich Bluhmki
- 3 Medical Affairs, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Geoffrey Donnan
- 4 University of Melbourne, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | | | - Marc Fatar
- 5 Department of Neurology, Universitätsmedizin Mannheim, University of Heidelber, Heidelberg, Germany
| | - Christof Kessler
- 6 Department ogf Neurology, Ernst Moritz Arndt-University of Greifswald, Greifswald, Germany
| | - Carlos Molina
- 7 Department of Neurology, University of Barcelona, Hospital vall d'hebron, Barcelona, Spain
| | - Didier Leys
- 8 Department of Neurology, Lille, France, Univ Lille; Inserm; CHU Lille; UMR-S
| | - Girish Muddegowda
- 9 Department of Neurology, University of Nottingham, Nottingham, United Kingdom
| | - Sven Poli
- 10 Department of Neurology, University of Tübingen, Tübingen, Germany
| | | | - Stefan Schwab
- 12 Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Joaquin Serena
- 13 Department of Neurology, Hospital Universitari de Girona Doctor Josep Trueta, Girona, Spain
| | - Danilo Toni
- 14 Department of Neurology, Sapienza University of Rome, Rome, Italy
| | - Nils Wahlgren
- 15 Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Werner Hacke
- 16 Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | | |
Collapse
|
29
|
Fuhrer H, Schönenberger S, Niesen WD, Seide S, Meyne J, Gerner ST, Vollmuth C, Beck C, Meckel S, Schocke M, Wodarg F, Huttner HB, Möhlenbruch MA, Kieser M, Ringleb P, Neugebauer H. Endovascular stroke treatment's impact on malignant type of edema (ESTIMATE). J Neurol 2018; 266:223-231. [PMID: 30470996 DOI: 10.1007/s00415-018-9127-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke and large vessel occlusion, the prognosis has improved tremendously since the implementation of endovascular thrombectomy (EVT). The effect of EVT on the incidence of malignant middle cerebral artery infarctions (MMI) has not been studied before. METHODS ESTIMATE, a multicenter retrospective study, evaluates data of ischemic stroke patients with occlusion in the anterior circulation in the years of 2007-2015 comparing three treatment options (no therapy; IV-TPA; IV-TPA plus EVT or EVT only). Primary endpoint of the study was the incidence of MMI on follow-up imaging and mortality rates. Secondary endpoints were functional outcome, further clinical and imaging data. Logistic and Cox-regression models with a propensity score weighting approach were applied to evaluate differences between treatment groups. RESULTS In 2161 patients over 9 years, EVT reduced the MMI rates significantly: patients without acute stroke treatment had increased odds for MMI of 1.57 [95% confidence interval (CI) 1.49-1.65]. In contrast, after treatment with IV-TPA, only we observed an OR of 0.88 (95% CI 0.83-0.94, p < 0.001), and after EVT an OR of 0.80 (95% CI 0.76-0.85, p < 0.001). This was more pronounced in larger pretreatment infarctions (ASPECTS < 5, p < 0.01). IV-TPA also lowers the MMI rates but not to the same extent. EVT-treated patients had increased survival rates (p < 0.05) and the best functional outcome at discharge. CONCLUSIONS The findings of this study illustrate that occurrence of MMI and mortality rates was significantly reduced in patients treated with EVT.
Collapse
Affiliation(s)
- Hannah Fuhrer
- Department of Neurology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.
| | - Silvia Schönenberger
- Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
| | - Svenja Seide
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Christoph Vollmuth
- Department of Neurology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Christopher Beck
- Department of Neuroradiology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Department of Nuclear medicine, University Hospital Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Stephan Meckel
- Department of Neuroradiology, University Hospital Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
| | - Michael Schocke
- Department of Neuroradiology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Fritz Wodarg
- Department of Neuroradiology, University Hospital Kiel, Arnold-Heller-Straße 9, 24105, Kiel, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | | |
Collapse
|
30
|
Román LS, Menon BK, Blasco J, Hernández-Pérez M, Dávalos A, Majoie CBLM, Campbell BCV, Guillemin F, Lingsma H, Anxionnat R, Epstein J, Saver JL, Marquering H, Wong JH, Lopes D, Reimann G, Desal H, Dippel DWJ, Coutts S, du Mesnil de Rochemont R, Yavagal D, Ferre JC, Roos YBWEM, Liebeskind DS, Lenthall R, Molina C, Al Ajlan FS, Reddy V, Dowlatshahi D, Sourour NA, Oppenheim C, Mitha AP, Davis SM, Weimar C, van Oostenbrugge RJ, Cobo E, Kleinig TJ, Donnan GA, van der Lugt A, Demchuk AM, Berkhemer OA, Boers AMM, Ford GA, Muir KW, Brown BS, Jovin T, van Zwam WH, Mitchell PJ, Hill MD, White P, Bracard S, Goyal M, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle J, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach Z, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S, Wakhloo A, Moonis M, Henniger N, Goddeau R, van den Berg R, Massari F, Minaeian A, Lozano JD, Ramzan M, Stout C, Patel A, Tunguturi A, Onteddu S, Carandang R, Howk M, Koudstaal PJ, Ribó M, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Meler P, Huerga E, Gelabert S, Coscojuela P, van Zwam WH, Tomasello A, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Rovira A, Molina CA, Millán M, Muñoz L, Roos YB, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, García Bermejo P, Remollo S, Castaño C, García-Sort R, van der Lugt A, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Dávalos A, Chamorro A, Urra X, Obach V, van Oostenbrugge RJ, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Ariño H, Aceituno A, Rudilosso S, Renu A, Majoie CB, Macho JM, San Roman L, Blasco J, López A, Macías N, Cardona P, Quesada H, Rubio F, Cano L, Lara B, Dippel DW, de Miquel MA, Aja L, Serena J, Cobo E, Albers GW, Lees KR, Arenillas J, Roberts R, Minhas P, Al-Ajlan F, Brown MM, Salluzzi M, Zimmel L, Patel S, Eesa M, Martí-Fàbregas J, Jankowitz B, Serena J, Salvat-Plana M, López-Cancio E, Bracard S, Liebig T, Ducrocq X, Anxionnat R, Baillot PA, Barbier C, Derelle AL, Lacour JC, Richard S, Samson Y, Sourour N, Baronnet-Chauvet F, Stijnen T, Clarencon F, Crozier S, Deltour S, Di Maria F, Le Bouc R, Leger A, Mutlu G, Rosso C, Szatmary Z, Yger M, Andersson T, Zavanone C, Bakchine S, Pierot L, Caucheteux N, Estrade L, Kadziolka K, Leautaud A, Renkes C, Serre I, Desal H, Mattle H, Guillon B, Boutoleau-Bretonniere C, Daumas-Duport B, De Gaalon S, Derkinderen P, Evain S, Herisson F, Laplaud DA, Lebouvier T, Lintia-Gaultier A, Wahlgren N, Pouclet-Courtemanche H, Rouaud T, Rouaud Jaffrenou V, Schunck A, Sevin-Allouet M, Toulgoat F, Wiertlewski S, Gauvrit JY, Ronziere T, Cahagne V, van der Heijden E, Ferre JC, Pinel JF, Raoult H, Mas JL, Meder JF, Al Najjar-Carpentier AA, Birchenall J, Bodiguel E, Calvet D, Domigo V, Ghannouti N, Godon-Hardy S, Guiraud V, Lamy C, Majhadi L, Morin L, Naggara O, Trystram D, Turc G, Berge J, Sibon I, Fleitour N, Menegon P, Barreau X, Rouanet F, Debruxelles S, Kazadi A, Renou P, Fleury O, Pasco-Papon A, Dubas F, Caroff J, Hooijenga I, Godard Ducceschi S, Hamon MA, Lecluse A, Marc G, Giroud M, Ricolfi F, Bejot Y, Chavent A, Gentil A, Kazemi A, Puppels C, Osseby GV, Voguet C, Mahagne MH, Sedat J, Chau Y, Suissa L, Lachaud S, Houdart E, Stapf C, Buffon Porcher F, Pellikaan W, Chabriat H, Guedin P, Herve D, Jouvent E, Mawet J, Saint-Maurice JP, Schneble HM, Turjman F, Nighoghossian N, Berhoune NN, Geerling A, Bouhour F, Cho TH, Derex L, Felix S, Gervais-Bernard H, Gory B, Manera L, Mechtouff L, Ritzenthaler T, Riva R, Lindl-Velema A, Salaris Silvio F, Tilikete C, Blanc R, Obadia M, Bartolini MB, Gueguen A, Piotin M, Pistocchi S, Redjem H, Drouineau J, van Vemde G, Neau JP, Godeneche G, Lamy M, Marsac E, Velasco S, Clavelou P, Chabert E, Bourgois N, Cornut-Chauvinc C, Ferrier A, de Ridder A, Gabrillargues J, Jean B, Marques AR, Vitello N, Detante O, Barbieux M, Boubagra K, Favre Wiki I, Garambois K, Tahon F, Greebe P, Ashok V, Voguet C, Coskun O, Guedin P, Rodesch G, Lapergue B, Bourdain F, Evrard S, Graveleau P, Decroix JP, de Bont-Stikkelbroeck J, Wang A, Sellal F, Ahle G, Carelli G, Dugay MH, Gaultier C, Lebedinsky AP, Lita L, Musacchio RM, Renglewicz-Destuynder C, de Meris J, Tournade A, Vuillemet F, Montoro FM, Mounayer C, Faugeras F, Gimenez L, Labach C, Lautrette G, Denier C, Saliou G, Janssen K, Chassin O, Dussaule C, Melki E, Ozanne A, Puccinelli F, Sachet M, Sarov M, Bonneville JF, Moulin T, Biondi A, Struijk W, De Bustos Medeiros E, Vuillier F, Courtheoux P, Viader F, Apoil-Brissard M, Bataille M, Bonnet AL, Cogez J, Kazemi A, Touze E, Licher S, Leclerc X, Leys D, Aggour M, Aguettaz P, Bodenant M, Cordonnier C, Deplanque D, Girot M, Henon H, Kalsoum E, Boodt N, Lucas C, Pruvo JP, Zuniga P, Bonafé A, Arquizan C, Costalat V, Machi P, Mourand I, Riquelme C, Bounolleau P, Ros A, Arteaga C, Faivre A, Bintner M, Tournebize P, Charlin C, Darcel F, Gauthier-Lasalarie P, Jeremenko M, Mouton S, Zerlauth JB, Venema E, Lamy C, Hervé D, Hassan H, Gaston A, Barral FG, Garnier P, Beaujeux R, Wolff V, Herbreteau D, Debiais S, Slokkers I, Murray A, Ford G, Muir KW, White P, Brown MM, Clifton A, Freeman J, Ford I, Markus H, Wardlaw J, Ganpat RJ, Lees KR, Molyneux A, Robinson T, Lewis S, Norrie J, Robertson F, Perry R, Dixit A, Cloud G, Clifton A, Mulder M, Madigan J, Roffe C, Nayak S, Lobotesis K, Smith C, Herwadkar A, Kandasamy N, Goddard T, Bamford J, Subramanian G, Saiedie N, Lenthall R, Littleton E, Lamin S, Storey K, Ghatala R, Banaras A, Aeron-Thomas J, Hazel B, Maguire H, Veraque E, Heshmatollah A, Harrison L, Keshvara R, Cunningham J, Schipperen S, Vinken S, van Boxtel T, Koets J, Boers M, Santos E, Borst J, Jansen I, Kappelhof M, Lucas M, Geuskens R, Barros RS, Dobbe R, Csizmadia M, Hill MD, Goyal M, Demchuk AM, Menon BK, Eesa M, Ryckborst KJ, Wright MR, Kamal NR, Andersen L, Randhawa PA, Stewart T, Patil S, Minhas P, Almekhlafi M, Mishra S, Clement F, Sajobi T, Shuaib A, Montanera WJ, Roy D, Silver FL, Jovin TG, Frei DF, Sapkota B, Rempel JL, Thornton J, Williams D, Tampieri D, Poppe AY, Dowlatshahi D, Wong JH, Mitha AP, Subramaniam S, Hull G, Lowerison MW, Sajobi T, Salluzzi M, Wright MR, Maxwell M, Lacusta S, Drupals E, Armitage K, Barber PA, Smith EE, Morrish WF, Coutts SB, Derdeyn C, Demaerschalk B, Yavagal D, Martin R, Brant R, Yu Y, Willinsky RA, Montanera WJ, Weill A, Kenney C, Aram H, Stewart T, Stys PK, Watson TW, Klein G, Pearson D, Couillard P, Trivedi A, Singh D, Klourfeld E, Imoukhuede O, Nikneshan D, Blayney S, Reddy R, Choi P, Horton M, Musuka T, Dubuc V, Field TS, Desai J, Adatia S, Alseraya A, Nambiar V, van Dijk R, Wong JH, Mitha AP, Morrish WF, Eesa M, Newcommon NJ, Shuaib A, Schwindt B, Butcher KS, Jeerakathil T, Buck B, Khan K, Naik SS, Emery DJ, Owen RJ, Kotylak TB, Ashforth RA, Yeo TA, McNally D, Siddiqui M, Saqqur M, Hussain D, Kalashyan H, Manosalva A, Kate M, Gioia L, Hasan S, Mohammad A, Muratoglu M, Williams D, Thornton J, Cullen A, Brennan P, O'Hare A, Looby S, Hyland D, Duff S, McCusker M, Hallinan B, Lee S, McCormack J, Moore A, O'Connor M, Donegan C, Brewer L, Martin A, Murphy S, O'Rourke K, Smyth S, Kelly P, Lynch T, Daly T, O'Brien P, O'Driscoll A, Martin M, Daly T, Collins R, Coughlan T, McCabe D, Murphy S, O'Neill D, Mulroy M, Lynch O, Walsh T, O'Donnell M, Galvin T, Harbison J, McElwaine P, Mulpeter K, McLoughlin C, Reardon M, Harkin E, Dolan E, Watts M, Cunningham N, Fallon C, Gallagher S, Cotter P, Crowe M, Doyle R, Noone I, Lapierre M, Coté VA, Lanthier S, Odier C, Durocher A, Raymond J, Weill A, Daneault N, Deschaintre Y, Jankowitz B, Baxendell L, Massaro L, Jackson-Graves C, Decesare S, Porter P, Armbruster K, Adams A, Billigan J, Oakley J, Ducruet A, Jadhav A, Giurgiutiu DV, Aghaebrahim A, Reddy V, Hammer M, Starr M, Totoraitis V, Wechsler L, Streib S, Rangaraju S, Campbell D, Rocha M, Gulati D, Silver FL, Krings T, Kalman L, Cayley A, Williams J, Stewart T, Wiegner R, Casaubon LK, Jaigobin C, del Campo JM, Elamin E, Schaafsma JD, Willinsky RA, Agid R, Farb R, ter Brugge K, Sapkoda BL, Baxter BW, Barton K, Knox A, Porter A, Sirelkhatim A, Devlin T, Dellinger C, Pitiyanuvath N, Patterson J, Nichols J, Quarfordt S, Calvert J, Hawk H, Fanale C, Frei DF, Bitner A, Novak A, Huddle D, Bellon R, Loy D, Wagner J, Chang I, Lampe E, Spencer B, Pratt R, Bartt R, Shine S, Dooley G, Nguyen T, Whaley M, McCarthy K, Teitelbaum J, Tampieri D, Poon W, Campbell N, Cortes M, Dowlatshahi D, Lum C, Shamloul R, Robert S, Stotts G, Shamy M, Steffenhagen N, Blacquiere D, Hogan M, AlHazzaa M, Basir G, Lesiuk H, Iancu D, Santos M, Choe H, Weisman DC, Jonczak K, Blue-Schaller A, Shah Q, MacKenzie L, Klein B, Kulandaivel K, Kozak O, Gzesh DJ, Harris LJ, Khoury JS, Mandzia J, Pelz D, Crann S, Fleming L, Hesser K, Beauchamp B, Amato-Marzialli B, Boulton M, Lopez-Ojeda P, Sharma M, Lownie S, Chan R, Swartz R, Howard P, Golob D, Gladstone D, Boyle K, Boulos M, Hopyan J, Yang V, Da Costa L, Holmstedt CA, Turk AS, Navarro R, Jauch E, Ozark S, Turner R, Phillips S, Shankar J, Jarrett J, Gubitz G, Maloney W, Vandorpe R, Schmidt M, Heidenreich J, Hunter G, Kelly M, Whelan R, Peeling L, Burns PA, Hunter A, Wiggam I, Kerr E, Watt M, Fulton A, Gordon P, Rennie I, Flynn P, Smyth G, O'Leary S, Gentile N, Linares G, McNelis P, Erkmen K, Katz P, Azizi A, Weaver M, Jungreis C, Faro S, Shah P, Reimer H, Kalugdan V, Saposnik G, Bharatha A, Li Y, Kostyrko P, Santos M, Marotta T, Montanera W, Sarma D, Selchen D, Spears J, Heo JH, Jeong K, Kim DJ, Kim BM, Kim YD, Song D, Lee KJ, Yoo J, Bang OY, Rho S, Lee J, Jeon P, Kim KH, Cha J, Kim SJ, Ryoo S, Lee MJ, Sohn SI, Kim CH, Ryu HG, Hong JH, Chang HW, Lee CY, Rha J, Davis SM, Donnan GA, Campbell BCV, Mitchell PJ, Churilov L, Yan B, Dowling R, Yassi N, Oxley TJ, Wu TY, Silver G, McDonald A, McCoy R, Kleinig TJ, Scroop R, Dewey HM, Simpson M, Brooks M, Coulton B, Krause M, Harrington TJ, Steinfort B, Faulder K, Priglinger M, Day S, Phan T, Chong W, Holt M, Chandra RV, Ma H, Young D, Wong K, Wijeratne T, Tu H, Mackay E, Celestino S, Bladin CF, Loh PS, Gilligan A, Ross Z, Coote S, Frost T, Parsons MW, Miteff F, Levi CR, Ang T, Spratt N, Kaauwai L, Badve M, Rice H, de Villiers L, Barber PA, McGuinness B, Hope A, Moriarty M, Bennett P, Wong A, Coulthard A, Lee A, Jannes J, Field D, Sharma G, Salinas S, Cowley E, Snow B, Kolbe J, Stark R, King J, Macdonnell R, Attia J, D'Este C, Saver JL, Goyal M, Diener HC, Levy EI, Bonafé A, Mendes Pereira V, Jahan R, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, von Kummer R, Smith W, Turjman F, Hamilton S, Chiacchierini R, Amar A, Sanossian N, Loh Y, Devlin T, Baxter B, Hawk H, Sapkota B, Quarfordt S, Sirelkhatim A, Dellinger C, Barton K, Reddy VK, Ducruet A, Jadhav A, Horev A, Giurgiutiu DV, Totoraitis V, Hammer M, Jankowitz B, Wechsler L, Rocha M, Gulati D, Campbell D, Star M, Baxendell L, Oakley J, Siddiqui A, Hopkins LN, Snyder K, Sawyer R, Hall S, Costalat V, Riquelme C, Machi P, Omer E, Arquizan C, Mourand I, Charif M, Ayrignac X, Menjot de Champfleur N, Leboucq N, Gascou G, Moynier M, du Mesnil de Rochemont R, Singer O, Berkefeld J, Foerch C, Lorenz M, Pfeilschifer W, Hattingen E, Wagner M, You SJ, Lescher S, Braun H, Dehkharghani S, Belagaje SR, Anderson A, Lima A, Obideen M, Haussen D, Dharia R, Frankel M, Patel V, Owada K, Saad A, Amerson L, Horn C, Doppelheuer S, Schindler K, Lopes DK, Chen M, Moftakhar R, Anton C, Smreczak M, Carpenter JS, Boo S, Rai A, Roberts T, Tarabishy A, Gutmann L, Brooks C, Brick J, Domico J, Reimann G, Hinrichs K, Becker M, Heiss E, Selle C, Witteler A, Al-Boutros S, Danch MJ, Ranft A, Rohde S, Burg K, Weimar C, Zegarac V, Hartmann C, Schlamann M, Göricke S, Ringlestein A, Wanke I, Mönninghoff C, Dietzold M, Budzik R, Davis T, Eubank G, Hicks WJ, Pema P, Vora N, Mejilla J, Taylor M, Clark W, Rontal A, Fields J, Peterson B, Nesbit G, Lutsep H, Bozorgchami H, Priest R, Ologuntoye O, Barnwell S, Dogan A, Herrick K, Takahasi C, Beadell N, Brown B, Jamieson S, Hussain MS, Russman A, Hui F, Wisco D, Uchino K, Khawaja Z, Katzan I, Toth G, Cheng-Ching E, Bain M, Man S, Farrag A, George P, John S, Shankar L, Drofa A, Dahlgren R, Bauer A, Itreat A, Taqui A, Cerejo R, Richmond A, Ringleb P, Bendszus M, Möhlenbruch M, Reiff T, Amiri H, Purrucker J, Herweh C, Pham M, Menn O, Ludwig I, Acosta I, Villar C, Morgan W, Sombutmai C, Hellinger F, Allen E, Bellew M, Gandhi R, Bonwit E, Aly J, Ecker RD, Seder D, Morris J, Skaletsky M, Belden J, Baker C, Connolly LS, Papanagiotou P, Roth C, Kastrup A, Politi M, Brunner F, Alexandrou M, Merdivan H, Ramsey C, Given II C, Renfrow S, Deshmukh V, Sasadeusz K, Vincent F, Thiesing JT, Putnam J, Bhatt A, Kansara A, Caceves D, Lowenkopf T, Yanase L, Zurasky J, Dancer S, Freeman B, Scheibe-Mirek T, Robison J, Rontal A, Roll J, Clark D, Rodriguez M, Fitzsimmons BFM, Zaidat O, Lynch JR, Lazzaro M, Larson T, Padmore L, Das E, Farrow-Schmidt A, Hassan A, Tekle W, Cate C, Jansen O, Cnyrim C, Wodarg F, Wiese C, Binder A, Riedel C, Rohr A, Lang N, Laufs H, Krieter S, Remonda L, Diepers M, Añon J, Nedeltchev K, Kahles T, Biethahn S, Lindner M, Chang V, Gächter C, Esperon C, Guglielmetti M, Arenillas Lara JF, Martínez Galdámez M, Calleja Sanz AI, Cortijo Garcia E, Garcia Bermejo P, Perez S, Mulero Carrillo P, Crespo Vallejo E, Ruiz Piñero M, Lopez Mesonero L, Reyes Muñoz FJ, Brekenfeld C, Buhk JH, Krützelmann A, Thomalla G, Cheng B, Beck C, Hoppe J, Goebell E, Holst B, Grzyska U, Wortmann G, Starkman S, Duckwiler G, Jahan R, Rao N, Sheth S, Ng K, Noorian A, Szeder V, Nour M, McManus M, Huang J, Tarpley J, Tateshima S, Gonzalez N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D. Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 2018; 17:895-904. [DOI: 10.1016/s1474-4422(18)30242-4] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022]
|
31
|
Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, Cheripelli B, Cho TH, Fazekas F, Fiehler J, Ford I, Galinovic I, Gellissen S, Golsari A, Gregori J, Günther M, Guibernau J, Häusler KG, Hennerici M, Kemmling A, Marstrand J, Modrau B, Neeb L, Perez de la Ossa N, Puig J, Ringleb P, Roy P, Scheel E, Schonewille W, Serena J, Sunaert S, Villringer K, Wouters A, Thijs V, Ebinger M, Endres M, Fiebach JB, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Gerloff C. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. N Engl J Med 2018; 379:611-622. [PMID: 29766770 DOI: 10.1056/nejmoa1804355] [Citation(s) in RCA: 717] [Impact Index Per Article: 119.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Under current guidelines, intravenous thrombolysis is used to treat acute stroke only if it can be ascertained that the time since the onset of symptoms was less than 4.5 hours. We sought to determine whether patients with stroke with an unknown time of onset and features suggesting recent cerebral infarction on magnetic resonance imaging (MRI) would benefit from thrombolysis with the use of intravenous alteplase. METHODS In a multicenter trial, we randomly assigned patients who had an unknown time of onset of stroke to receive either intravenous alteplase or placebo. All the patients had an ischemic lesion that was visible on MRI diffusion-weighted imaging but no parenchymal hyperintensity on fluid-attenuated inversion recovery (FLAIR), which indicated that the stroke had occurred approximately within the previous 4.5 hours. We excluded patients for whom thrombectomy was planned. The primary end point was favorable outcome, as defined by a score of 0 or 1 on the modified Rankin scale of neurologic disability (which ranges from 0 [no symptoms] to 6 [death]) at 90 days. A secondary outcome was the likelihood that alteplase would lead to lower ordinal scores on the modified Rankin scale than would placebo (shift analysis). RESULTS The trial was stopped early owing to cessation of funding after the enrollment of 503 of an anticipated 800 patients. Of these patients, 254 were randomly assigned to receive alteplase and 249 to receive placebo. A favorable outcome at 90 days was reported in 131 of 246 patients (53.3%) in the alteplase group and in 102 of 244 patients (41.8%) in the placebo group (adjusted odds ratio, 1.61; 95% confidence interval [CI], 1.09 to 2.36; P=0.02). The median score on the modified Rankin scale at 90 days was 1 in the alteplase group and 2 in the placebo group (adjusted common odds ratio, 1.62; 95% CI, 1.17 to 2.23; P=0.003). There were 10 deaths (4.1%) in the alteplase group and 3 (1.2%) in the placebo group (odds ratio, 3.38; 95% CI, 0.92 to 12.52; P=0.07). The rate of symptomatic intracranial hemorrhage was 2.0% in the alteplase group and 0.4% in the placebo group (odds ratio, 4.95; 95% CI, 0.57 to 42.87; P=0.15). CONCLUSIONS In patients with acute stroke with an unknown time of onset, intravenous alteplase guided by a mismatch between diffusion-weighted imaging and FLAIR in the region of ischemia resulted in a significantly better functional outcome and numerically more intracranial hemorrhages than placebo at 90 days. (Funded by the European Union Seventh Framework Program; WAKE-UP ClinicalTrials.gov number, NCT01525290; and EudraCT number, 2011-005906-32 .).
Collapse
Affiliation(s)
- Götz Thomalla
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Claus Z Simonsen
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Florent Boutitie
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Grethe Andersen
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Yves Berthezene
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Bastian Cheng
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Bharath Cheripelli
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Tae-Hee Cho
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Franz Fazekas
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Jens Fiehler
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Ian Ford
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Ivana Galinovic
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Susanne Gellissen
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Amir Golsari
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Johannes Gregori
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Matthias Günther
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Jorge Guibernau
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Karl Georg Häusler
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Michael Hennerici
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - André Kemmling
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Jacob Marstrand
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Boris Modrau
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Lars Neeb
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Natalia Perez de la Ossa
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Josep Puig
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Peter Ringleb
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Pascal Roy
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Enno Scheel
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Wouter Schonewille
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Joaquin Serena
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Stefan Sunaert
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Kersten Villringer
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Anke Wouters
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Vincent Thijs
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Martin Ebinger
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Matthias Endres
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Jochen B Fiebach
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Robin Lemmens
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Keith W Muir
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Norbert Nighoghossian
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Salvador Pedraza
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Christian Gerloff
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| |
Collapse
|
32
|
Kloss M, Grond-Ginsbach C, Ringleb P, Hausser I, Hacke W, Brandt T. Recurrence of cervical artery dissection. Neurology 2018; 90:e1372-e1378. [DOI: 10.1212/wnl.0000000000005324] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 01/10/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo explore the recurrence of cervical artery dissection (CeAD).MethodsA single-center consecutive series of 282 CeAD patients was prospectively recruited during first admission from 1995 to 2012. Patients with a follow-up of at least 1 year (n = 238) were eligible for the current analysis. All patients with clinical symptoms or signs of recurrent CeAD on ultrasound were examined by MRI. Dermal connective tissue morphology was studied in 108 (45.4%) patients.ResultsMedian follow-up was 52 months (range 12–204 months). In all, 221 (92.8%) patients presented with monophasic CeAD, including 188 (79.0%) patients with a single CeAD event, 11 (4.6%) with simultaneous dissections in multiple cervical arteries, and 22 (9.2%) with subsequent events within a single phase of 4 weeks. Seventeen patients (7.1%) had late (>1 month after the initial event) recurrent CeAD events, including 5 (2.1%) with multiple recurrences. Patients with late recurrences were younger (37.5 ± 6.9 years) than those without (43.8 ± 9.9; p = 0.011). Ischemic stroke occurred in 164 (68.9%) patients at first diagnosis, but only 4 of 46 (8.7%) subsequent events caused stroke (p < 0.0001), while 19 (41.3%) were asymptomatic. Connective tissue abnormalities were found in 54 (56.3%) patients with monophasic and 8 (66.7%) with late recurrent dissections (p = 0.494).ConclusionTwenty-two (9.2%) patients had new CeAD events within 1 month and 17 (7.1%) later recurrences. The risk for new events was significantly higher (about 60-fold) during the acute phase than during later follow-up. Connective tissue abnormalities were not more frequent in patients with late recurrent events than in those with monophasic CeAD.
Collapse
|
33
|
Ringleb P, Steiner T, Knaup P, Hacke W, Haux R, Brigl B. An Integrated Approach for a Knowledge-based Clinical Workstation: Architecture and Experience. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1634492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Abstract:Today, the demand for medical decision support to improve the quality of patient care and to reduce costs in health services is generally recognized. Nevertheless, decision support is not yet established in daily routine within hospital information systems which often show a heterogeneous architecture but offer possibilities of interoperability. Currently, the integration of decision support functions into clinical workstations is the most promising way. Therefore, we first discuss aspects of integrating decision support into clinical workstations including clinical needs, integration of database and knowledge base, knowledge sharing and reuse and the role of standardized terminology. In addition, we draw up functional requirements to support the physician dealing with patient care, medical research and administrative tasks. As a consequence, we propose a general architecture of an integrated knowledge-based clinical workstation. Based on an example application we discuss our experiences concerning clinical applicability and relevance. We show that, although our approach promotes the integration of decision support into hospital information systems, the success of decision support depends above all on an adequate transformation of clinical needs.
Collapse
|
34
|
Nagel S, Bouslama M, Krause L, Küpper C, Messer M, Petersen M, Lowens S, Herzberg M, Ringleb P, Möhlenbruch M, Tiedt S, Lima F, Haussen D, Smith W, Lev M, Nogueira R. Abstract 108: Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions - A Multicenter and Matched Analysis. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In patients with acute ischemic strokes (AIS) and milder symptoms (NIHSS</=5) harboring a large vessel occlusion (LVO) best clinical management is unclear. To describe the safety and efficacy of immediate mechanical thrombectomy (MT) in patients with LVO and milder symptoms versus best medical management, including rescue MT.
Methods:
Retrospective cohort study on consecutive patients for a descriptive analysis regarding clinical and safety outcomes. From local prospectively run databases of six international comprehensive stroke centers data was pooled. 300 Patients with LVO (distal internal carotid artery, MCA-M1 and/or M2 segments, or basilar artery with or without tandem occlusions) and milder symptoms were identified and divided into two groups for analysis: immediate MT (i-MT) or best medical management which included rescue MT after neurological deterioration (n/r-MT). Uni- and multivariate analysis were performed to compare baseline and outcome variables across the two groups. Additional comparisons were performed after patient-level matching for age, baseline NIHSS and occlusion site. The primary outcome was defined as good outcome (modified rankin scale [mRS] 0-2) at day 90. Secondary outcomes were, among others, modified shift analyses at day 90. Safety outcome was symptomatic intracranial hemorrhage (sICH) as defined by the European Cooperative Acute Stroke Study (ECASS) II and mortality at day 90.
Results:
Compared to n/r-MT (n=220), patients with i-MT (n=80) were younger (65.3+/-13.5 vs. 69.5+/-14.1, p=0.021), had more often atrial fibrillation (44.8% vs. 28.2%, p=0.012), higher baseline NIHSS (4, 0-5 vs. 3, 0-5, p=0.005), more MCA-M1 (41.3% vs. 21.9%) and less MCA-M2 (28.8% vs. 49.3%, p=0.016) occlusions. The adjusted odds ratio for good outcome was 3.1 95% CI: 1.4-6.9 favoring i-MT. In the matched analysis, there was a 14.4% absolute difference in good outcome (84.4% vs. 70.1%, p=0.03) and a significant modified mRS shift (OR 2.29, 95% CI: 1.05-4.98) at day 90 favoring i-MT. There were no safety concerns.
Conclusions and Relevance:
The observed benefit-safety profile favors immediate MT in patients with milder symptoms and LVO.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Steffen Tiedt
- Institute for Stroke and Dementia Rsch, Munich, Germany
| | | | | | - Wade Smith
- Univ of California San Francisco, San Fransico, CA
| | | | | |
Collapse
|
35
|
Campbell BCV, van Zwam WH, Goyal M, Menon BK, Dippel DWJ, Demchuk AM, Bracard S, White P, Dávalos A, Majoie CBLM, van der Lugt A, Ford GA, de la Ossa NP, Kelly M, Bourcier R, Donnan GA, Roos YBWEM, Bang OY, Nogueira RG, Devlin TG, van den Berg LA, Clarençon F, Burns P, Carpenter J, Berkhemer OA, Yavagal DR, Pereira VM, Ducrocq X, Dixit A, Quesada H, Epstein J, Davis SM, Jansen O, Rubiera M, Urra X, Micard E, Lingsma HF, Naggara O, Brown S, Guillemin F, Muir KW, van Oostenbrugge RJ, Saver JL, Jovin TG, Hill MD, Mitchell PJ, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle J, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach Z, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Wakhloo A, Moonis M, Henninger N, Goddeau R, Massari F, Minaeian A, Lozano JD, Ramzan M, Stout C, Patel A, Majoie CB, Tunguturi A, Onteddu S, Carandang R, Howk M, Ribó M, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Dippel DW, Meler P, Huerga E, Gelabert S, Coscojuela P, Tomasello A, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Brown MM, Rovira A, Molina CA, Millán M, Muñoz L, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, Liebig T, García Bermejo P, Remollo S, Castaño C, García-Sort R, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Stijnen T, Dávalos A, Chamorro A, Urra X, Obach V, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Andersson T, Ariño H, Aceituno A, Rudilosso S, Renu A, Macho JM, San Roman L, Blasco J, López A, Macías N, Cardona P, Mattle H, Quesada H, Rubio F, Cano L, Lara B, de Miquel MA, Aja L, Serena J, Cobo E, Albers GW, Lees KR, Wahlgren N, Arenillas J, Roberts R, Minhas P, Al-Ajlan F, Salluzzi M, Zimmel L, Patel S, Eesa M, Martí-Fàbregas J, Jankowitz B, van der Heijden E, Serena J, Salvat-Plana M, López-Cancio E, Bracard S, Ducrocq X, Anxionnat R, Baillot PA, Barbier C, Derelle AL, Lacour JC, Ghannouti N, Richard S, Samson Y, Sourour N, Baronnet-Chauvet F, Clarencon F, Crozier S, Deltour S, Di Maria F, Le Bouc R, Leger A, Fleitour N, Mutlu G, Rosso C, Szatmary Z, Yger M, Zavanone C, Bakchine S, Pierot L, Caucheteux N, Estrade L, Kadziolka K, Hooijenga I, Leautaud A, Renkes C, Serre I, Desal H, Guillon B, Boutoleau-Bretonniere C, Daumas-Duport B, De Gaalon S, Derkinderen P, Evain S, Puppels C, Herisson F, Laplaud DA, Lebouvier T, Lintia-Gaultier A, Pouclet-Courtemanche H, Rouaud T, Rouaud Jaffrenou V, Schunck A, Sevin-Allouet M, Toulgoat F, Pellikaan W, Wiertlewski S, Gauvrit JY, Ronziere T, Cahagne V, Ferre JC, Pinel JF, Raoult H, Mas JL, Meder JF, Al Najjar-Carpentier AA, Geerling A, Birchenall J, Bodiguel E, Calvet D, Domigo V, Godon-Hardy S, Guiraud V, Lamy C, Majhadi L, Morin L, Naggara O, Lindl-Velema A, Trystram D, Turc G, Berge J, Sibon I, Menegon P, Barreau X, Rouanet F, Debruxelles S, Kazadi A, Renou P, van Vemde G, Fleury O, Pasco-Papon A, Dubas F, Caroff J, Godard Ducceschi S, Hamon MA, Lecluse A, Marc G, Giroud M, Ricolfi F, de Ridder A, Bejot Y, Chavent A, Gentil A, Kazemi A, Osseby GV, Voguet C, Mahagne MH, Sedat J, Chau Y, Suissa L, Greebe P, Lachaud S, Houdart E, Stapf C, Buffon Porcher F, Chabriat H, Guedin P, Herve D, Jouvent E, Mawet J, Saint-Maurice JP, de Bont-Stikkelbroeck J, Schneble HM, Turjman F, Nighoghossian N, Berhoune NN, Bouhour F, Cho TH, Derex L, Felix S, Gervais-Bernard H, Gory B, de Meris J, Manera L, Mechtouff L, Ritzenthaler T, Riva R, Salaris Silvio F, Tilikete C, Blanc R, Obadia M, Bartolini MB, Gueguen A, Janssen K, Piotin M, Pistocchi S, Redjem H, Drouineau J, Neau JP, Godeneche G, Lamy M, Marsac E, Velasco S, Clavelou P, Struijk W, Chabert E, Bourgois N, Cornut-Chauvinc C, Ferrier A, Gabrillargues J, Jean B, Marques AR, Vitello N, Detante O, Barbieux M, Licher S, Boubagra K, Favre Wiki I, Garambois K, Tahon F, Ashok V, Voguet C, Coskun O, Guedin P, Rodesch G, Lapergue B, Boodt N, Bourdain F, Evrard S, Graveleau P, Decroix JP, Wang A, Sellal F, Ahle G, Carelli G, Dugay MH, Gaultier C, Ros A, Lebedinsky AP, Lita L, Musacchio RM, Renglewicz-Destuynder C, Tournade A, Vuillemet F, Montoro FM, Mounayer C, Faugeras F, Gimenez L, Venema E, Labach C, Lautrette G, Denier C, Saliou G, Chassin O, Dussaule C, Melki E, Ozanne A, Puccinelli F, Sachet M, Slokkers I, Sarov M, Bonneville JF, Moulin T, Biondi A, De Bustos Medeiros E, Vuillier F, Courtheoux P, Viader F, Apoil-Brissard M, Bataille M, Ganpat RJ, Bonnet AL, Cogez J, Kazemi A, Touze E, Leclerc X, Leys D, Aggour M, Aguettaz P, Bodenant M, Cordonnier C, Mulder M, Deplanque D, Girot M, Henon H, Kalsoum E, Lucas C, Pruvo JP, Zuniga P, Bonafé A, Arquizan C, Costalat V, Saiedie N, Machi P, Mourand I, Riquelme C, Bounolleau P, Arteaga C, Faivre A, Bintner M, Tournebize P, Charlin C, Darcel F, Heshmatollah A, Gauthier-Lasalarie P, Jeremenko M, Mouton S, Zerlauth JB, Lamy C, Hervé D, Hassan H, Gaston A, Barral FG, Garnier P, Schipperen S, Beaujeux R, Wolff V, Herbreteau D, Debiais S, Murray A, Ford G, Muir KW, White P, Brown MM, Clifton A, Vinken S, Freeman J, Ford I, Markus H, Wardlaw J, Lees KR, Molyneux A, Robinson T, Lewis S, Norrie J, Robertson F, van Boxtel T, Perry R, Dixit A, Cloud G, Clifton A, Madigan J, Roffe C, Nayak S, Lobotesis K, Smith C, Herwadkar A, Koets J, Kandasamy N, Goddard T, Bamford J, Subramanian G, Lenthall R, Littleton E, Lamin S, Storey K, Ghatala R, Banaras A, Boers M, Aeron-Thomas J, Hazel B, Maguire H, Veraque E, Harrison L, Keshvara R, Cunningham J, Santos E, Borst J, Jansen I, Kappelhof M, Lucas M, Geuskens R, Barros RS, Dobbe R, Csizmadia M, Hill MD, Goyal M, Demchuk AM, Menon BK, Eesa M, Ryckborst KJ, Wright MR, Kamal NR, Andersen L, Randhawa PA, Stewart T, Patil S, Minhas P, Almekhlafi M, Mishra S, Clement F, Sajobi T, Shuaib A, Montanera WJ, Roy D, Silver FL, Jovin TG, Frei DF, Sapkota B, Rempel JL, Thornton J, Williams D, Tampieri D, Poppe AY, Dowlatshahi D, Wong JH, Mitha AP, Subramaniam S, Hull G, Lowerison MW, Sajobi T, Salluzzi M, Wright MR, Maxwell M, Lacusta S, Drupals E, Armitage K, Barber PA, Smith EE, Morrish WF, Coutts SB, Derdeyn C, Demaerschalk B, Yavagal D, Martin R, Brant R, Yu Y, Willinsky RA, Montanera WJ, Weill A, Kenney C, Aram H, Stewart T, Stys PK, Watson TW, Klein G, Pearson D, Couillard P, Trivedi A, Singh D, Klourfeld E, Imoukhuede O, Nikneshan D, Blayney S, Reddy R, Choi P, Horton M, Musuka T, Dubuc V, Field TS, Desai J, Adatia S, Alseraya A, Nambiar V, van Dijk R, Wong JH, Mitha AP, Morrish WF, Eesa M, Newcommon NJ, Shuaib A, Schwindt B, Butcher KS, Jeerakathil T, Buck B, Khan K, Naik SS, Emery DJ, Owen RJ, Kotylak TB, Ashforth RA, Yeo TA, McNally D, Siddiqui M, Saqqur M, Hussain D, Kalashyan H, Manosalva A, Kate M, Gioia L, Hasan S, Mohammad A, Muratoglu M, Williams D, Thornton J, Cullen A, Brennan P, O'Hare A, Looby S, Hyland D, Duff S, McCusker M, Hallinan B, Lee S, McCormack J, Moore A, O'Connor M, Donegan C, Brewer L, Martin A, Murphy S, O'Rourke K, Smyth S, Kelly P, Lynch T, Daly T, O'Brien P, O'Driscoll A, Martin M, Daly T, Collins R, Coughlan T, McCabe D, Murphy S, O'Neill D, Mulroy M, Lynch O, Walsh T, O'Donnell M, Galvin T, Harbison J, McElwaine P, Mulpeter K, McLoughlin C, Reardon M, Harkin E, Dolan E, Watts M, Cunningham N, Fallon C, Gallagher S, Cotter P, Crowe M, Doyle R, Noone I, Lapierre M, Coté VA, Lanthier S, Odier C, Durocher A, Raymond J, Weill A, Daneault N, Deschaintre Y, Jankowitz B, Baxendell L, Massaro L, Jackson-Graves C, Decesare S, Porter P, Armbruster K, Adams A, Billigan J, Oakley J, Ducruet A, Jadhav A, Giurgiutiu DV, Aghaebrahim A, Reddy V, Hammer M, Starr M, Totoraitis V, Wechsler L, Streib S, Rangaraju S, Campbell D, Rocha M, Gulati D, Silver FL, Krings T, Kalman L, Cayley A, Williams J, Stewart T, Wiegner R, Casaubon LK, Jaigobin C, del Campo JM, Elamin E, Schaafsma JD, Willinsky RA, Agid R, Farb R, ter Brugge K, Sapkoda BL, Baxter BW, Barton K, Knox A, Porter A, Sirelkhatim A, Devlin T, Dellinger C, Pitiyanuvath N, Patterson J, Nichols J, Quarfordt S, Calvert J, Hawk H, Fanale C, Frei DF, Bitner A, Novak A, Huddle D, Bellon R, Loy D, Wagner J, Chang I, Lampe E, Spencer B, Pratt R, Bartt R, Shine S, Dooley G, Nguyen T, Whaley M, McCarthy K, Teitelbaum J, Tampieri D, Poon W, Campbell N, Cortes M, Dowlatshahi D, Lum C, Shamloul R, Robert S, Stotts G, Shamy M, Steffenhagen N, Blacquiere D, Hogan M, AlHazzaa M, Basir G, Lesiuk H, Iancu D, Santos M, Choe H, Weisman DC, Jonczak K, Blue-Schaller A, Shah Q, MacKenzie L, Klein B, Kulandaivel K, Kozak O, Gzesh DJ, Harris LJ, Khoury JS, Mandzia J, Pelz D, Crann S, Fleming L, Hesser K, Beauchamp B, Amato-Marzialli B, Boulton M, Lopez- Ojeda P, Sharma M, Lownie S, Chan R, Swartz R, Howard P, Golob D, Gladstone D, Boyle K, Boulos M, Hopyan J, Yang V, Da Costa L, Holmstedt CA, Turk AS, Navarro R, Jauch E, Ozark S, Turner R, Phillips S, Shankar J, Jarrett J, Gubitz G, Maloney W, Vandorpe R, Schmidt M, Heidenreich J, Hunter G, Kelly M, Whelan R, Peeling L, Burns PA, Hunter A, Wiggam I, Kerr E, Watt M, Fulton A, Gordon P, Rennie I, Flynn P, Smyth G, O'Leary S, Gentile N, Linares G, McNelis P, Erkmen K, Katz P, Azizi A, Weaver M, Jungreis C, Faro S, Shah P, Reimer H, Kalugdan V, Saposnik G, Bharatha A, Li Y, Kostyrko P, Santos M, Marotta T, Montanera W, Sarma D, Selchen D, Spears J, Heo JH, Jeong K, Kim DJ, Kim BM, Kim YD, Song D, Lee KJ, Yoo J, Bang OY, Rho S, Lee J, Jeon P, Kim KH, Cha J, Kim SJ, Ryoo S, Lee MJ, Sohn SI, Kim CH, Ryu HG, Hong JH, Chang HW, Lee CY, Rha J, Davis SM, Donnan GA, Campbell BCV, Mitchell PJ, Churilov L, Yan B, Dowling R, Yassi N, Oxley TJ, Wu TY, Silver G, McDonald A, McCoy R, Kleinig TJ, Scroop R, Dewey HM, Simpson M, Brooks M, Coulton B, Krause M, Harrington TJ, Steinfort B, Faulder K, Priglinger M, Day S, Phan T, Chong W, Holt M, Chandra RV, Ma H, Young D, Wong K, Wijeratne T, Tu H, Mackay E, Celestino S, Bladin CF, Loh PS, Gilligan A, Ross Z, Coote S, Frost T, Parsons MW, Miteff F, Levi CR, Ang T, Spratt N, Kaauwai L, Badve M, Rice H, de Villiers L, Barber PA, McGuinness B, Hope A, Moriarty M, Bennett P, Wong A, Coulthard A, Lee A, Jannes J, Field D, Sharma G, Salinas S, Cowley E, Snow B, Kolbe J, Stark R, King J, Macdonnell R, Attia J, D'Este C, Saver JL, Goyal M, Diener HC, Levy EI, Bonafé A, Mendes Pereira V, Jahan R, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, von Kummer R, Smith W, Turjman F, Hamilton S, Chiacchierini R, Amar A, Sanossian N, Loh Y, Devlin T, Baxter B, Hawk H, Sapkota B, Quarfordt S, Sirelkhatim A, Dellinger C, Barton K, Reddy VK, Ducruet A, Jadhav A, Horev A, Giurgiutiu DV, Totoraitis V, Hammer M, Jankowitz B, Wechsler L, Rocha M, Gulati D, Campbell D, Star M, Baxendell L, Oakley J, Siddiqui A, Hopkins LN, Snyder K, Sawyer R, Hall S, Costalat V, Riquelme C, Machi P, Omer E, Arquizan C, Mourand I, Charif M, Ayrignac X, Menjot de Champfleur N, Leboucq N, Gascou G, Moynier M, du Mesnil de Rochemont R, Singer O, Berkefeld J, Foerch C, Lorenz M, Pfeilschifer W, Hattingen E, Wagner M, You SJ, Lescher S, Braun H, Dehkharghani S, Belagaje SR, Anderson A, Lima A, Obideen M, Haussen D, Dharia R, Frankel M, Patel V, Owada K, Saad A, Amerson L, Horn C, Doppelheuer S, Schindler K, Lopes DK, Chen M, Moftakhar R, Anton C, Smreczak M, Carpenter JS, Boo S, Rai A, Roberts T, Tarabishy A, Gutmann L, Brooks C, Brick J, Domico J, Reimann G, Hinrichs K, Becker M, Heiss E, Selle C, Witteler A, Al-Boutros S, Danch MJ, Ranft A, Rohde S, Burg K, Weimar C, Zegarac V, Hartmann C, Schlamann M, Göricke S, Ringlestein A, Wanke I, Mönninghoff C, Dietzold M, Budzik R, Davis T, Eubank G, Hicks WJ, Pema P, Vora N, Mejilla J, Taylor M, Clark W, Rontal A, Fields J, Peterson B, Nesbit G, Lutsep H, Bozorgchami H, Priest R, Ologuntoye O, Barnwell S, Dogan A, Herrick K, Takahasi C, Beadell N, Brown B, Jamieson S, Hussain MS, Russman A, Hui F, Wisco D, Uchino K, Khawaja Z, Katzan I, Toth G, Cheng-Ching E, Bain M, Man S, Farrag A, George P, John S, Shankar L, Drofa A, Dahlgren R, Bauer A, Itreat A, Taqui A, Cerejo R, Richmond A, Ringleb P, Bendszus M, Möhlenbruch M, Reiff T, Amiri H, Purrucker J, Herweh C, Pham M, Menn O, Ludwig I, Acosta I, Villar C, Morgan W, Sombutmai C, Hellinger F, Allen E, Bellew M, Gandhi R, Bonwit E, Aly J, Ecker RD, Seder D, Morris J, Skaletsky M, Belden J, Baker C, Connolly LS, Papanagiotou P, Roth C, Kastrup A, Politi M, Brunner F, Alexandrou M, Merdivan H, Ramsey C, Given II C, Renfrow S, Deshmukh V, Sasadeusz K, Vincent F, Thiesing JT, Putnam J, Bhatt A, Kansara A, Caceves D, Lowenkopf T, Yanase L, Zurasky J, Dancer S, Freeman B, Scheibe-Mirek T, Robison J, Rontal A, Roll J, Clark D, Rodriguez M, Fitzsimmons BFM, Zaidat O, Lynch JR, Lazzaro M, Larson T, Padmore L, Das E, Farrow-Schmidt A, Hassan A, Tekle W, Cate C, Jansen O, Cnyrim C, Wodarg F, Wiese C, Binder A, Riedel C, Rohr A, Lang N, Laufs H, Krieter S, Remonda L, Diepers M, Añon J, Nedeltchev K, Kahles T, Biethahn S, Lindner M, Chang V, Gächter C, Esperon C, Guglielmetti M, Arenillas Lara JF, Martínez Galdámez M, Calleja Sanz AI, Cortijo Garcia E, Garcia Bermejo P, Perez S, Mulero Carrillo P, Crespo Vallejo E, Ruiz Piñero M, Lopez Mesonero L, Reyes Muñoz FJ, Brekenfeld C, Buhk JH, Krützelmann A, Thomalla G, Cheng B, Beck C, Hoppe J, Goebell E, Holst B, Grzyska U, Wortmann G, Starkman S, Duckwiler G, Jahan R, Rao N, Sheth S, Ng K, Noorian A, Szeder V, Nour M, McManus M, Huang J, Tarpley J, Tateshima S, Gonzalez N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol 2018; 17:47-53. [DOI: 10.1016/s1474-4422(17)30407-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/05/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
|
36
|
Abstract
IntroductionLarge-scale trials have shown that thrombolytic therapy reduces mortality and preserves left ventricular function in patients with acute myocardial infarction (AMI). As most ischemic strokes are thromboembolic in origin,1 there appears to be a rationale for the use of thrombolytic agents in the management of ischemic stroke.Thrombolytic agents differ in their mechanisms of action, but in general, they act by promoting the conversion of plasminogen into plasmin, resulting in fibrin degradation and clot dissolution. Streptokinase and recombinant tissue plasminogen activator (rt-PA) are the agents that have been the most widely investigated in stroke studies. Ancrod, the active agent in the venom of the Malayan pit viper, is primarily considered an anticoagulant, although it does stimulate endogenous t-PA release from the vascular endothelium and may enhance local thrombolysis. Urokinase is used in local, intra-arterial thrombolysis but has not been subjected to large clinical trials since computed tomography (CT) diagnosis became widely available.
Collapse
|
37
|
Häusler K, Ringleb P. Sekundärprävention des ischämischen Schlaganfalls bei Vorhofflimmern oder Karotisstenose. Aktuel Kardiol 2017. [DOI: 10.1055/s-0043-121630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDer ischämische Schlaganfall zählt zu den häufigsten Todesursachen in Deutschland und ist die führende Ursache für erworbene Behinderungen. Etwa 10 – 15% aller ischämischen Schlaganfälle werden mutmaßlich durch eine durch Vorhofflimmern bedingte zerebrale Embolie hervorgerufen. In einer durchaus vergleichbaren Häufigkeit sind arteriosklerotische Stenosen der A. carotis als Ursache einer zerebralen Ischämie anzunehmen. Dieser Übersichtsartikel fasst den aktuellen Wissensstand zur (medikamentösen) Sekundärprävention für Schlaganfallpatienten mit bekanntem Vorhofflimmern bzw. für Schlaganfallpatienten mit einer Karotisstenose zusammen und soll den ambulant behandelnden Ärzten eine Handhabe für die Praxis sein.
Collapse
Affiliation(s)
- Karl Häusler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin
- Centrum für Schlaganfallforschung Berlin (CSB), Charité – Universitätsmedizin Berlin
- Kompetenznetz Vorhofflimmern e. V., Münster
| | - Peter Ringleb
- Neurologische Klinik, UniversitatsKlinikum Heidelberg
| |
Collapse
|
38
|
Kumar R, Batchelder A, Saratzis A, AbuRahma A, Ringleb P, Lal B, Mas J, Steinbauer M, Naylor A. Restenosis after Carotid Interventions and Its Relationship with Recurrent Ipsilateral Stroke: A Systematic Review and Meta-analysis. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
39
|
De Meyer SF, Andersson T, Baxter B, Bendszus M, Brouwer P, Brinjikji W, Campbell BC, Costalat V, Dávalos A, Demchuk A, Dippel D, Fiehler J, Fischer U, Gilvarry M, Gounis MJ, Gralla J, Jansen O, Jovin T, Kallmes D, Khatri P, Lees KR, López-Cancio E, Majoie C, Marquering H, Narata AP, Nogueira R, Ringleb P, Siddiqui A, Szikora I, Vale D, von Kummer R, Yoo AJ, Hacke W, Liebeskind DS. Analyses of thrombi in acute ischemic stroke: A consensus statement on current knowledge and future directions. Int J Stroke 2017; 12:606-614. [PMID: 28534706 DOI: 10.1177/1747493017709671] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Limited data exist on clot composition and detailed characteristics of arterial thrombi associated with large vessel occlusion in acute ischemic stroke. Advances in endovascular thrombectomy and related imaging modalities have created a unique opportunity to analyze thrombi removed from cerebral arteries. Insights into thrombus composition, etiology, physical properties and neurovascular interactions may lead to future advancements in acute ischemic stroke treatment and improved clinical outcomes. Advances in imaging techniques may enhance clot characterization and inform therapeutic decision-making prior to treatment and reveal stroke etiology to guide secondary prevention. Current imaging techniques can provide some information about thrombi, but there remains much to evaluate about relationships that may exist among thrombus composition, occlusion characteristics and treatment outcomes. Improved pathophysiological characterization of clot types, their properties and how these properties change over time, together with clinical correlates from ongoing studies, may facilitate revascularization with thrombolysis and thrombectomy. Interdisciplinary approaches covering clinical, engineering and scientific aspects of thrombus research will be key to advancing the understanding of thrombi and improving acute ischemic stroke therapy. This consensus statement integrates recent research on clots and thrombi retrieved from cerebral arteries and provides a rationale for further analyses, including current opportunities and limitations.
Collapse
Affiliation(s)
- Simon F De Meyer
- 1 Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Tommy Andersson
- 2 Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,3 Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,4 Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Blaise Baxter
- 5 Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga
| | - Martin Bendszus
- 6 Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Patrick Brouwer
- 3 Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Waleed Brinjikji
- 7 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce Cv Campbell
- 8 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia
| | - Vincent Costalat
- 9 Interventional and Diagnostic Neuroradiology, Montpellier University Hospital, Montpellier, France
| | - Antoni Dávalos
- 10 Acute Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Andrew Demchuk
- 11 Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada
| | - Diederik Dippel
- 12 Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jens Fiehler
- 13 Department of Neuroradiology, University Medical Center, Hamburg, Germany
| | - Urs Fischer
- 14 Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Gilvarry
- 15 Neuravi Thromboembolic Initiative, Neuravi Ltd, Galway, Ireland
| | - Matthew J Gounis
- 16 Division of Neuroimaging and Intervention and New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jan Gralla
- 17 Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olav Jansen
- 18 Department of Radiology and Neuroradiology, UKSH, Kiel, Germany
| | - Tudor Jovin
- 19 Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David Kallmes
- 7 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pooja Khatri
- 20 Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kennedy R Lees
- 21 Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, UK
| | - Elena López-Cancio
- 10 Acute Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Charles Majoie
- 22 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Henk Marquering
- 22 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.,23 Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Raul Nogueira
- 25 Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Peter Ringleb
- 26 Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Adnan Siddiqui
- 27 Department of Neurosurgery, University of Buffalo, Buffalo, New York, USA
| | - István Szikora
- 28 Department of Neuroradiology, National Institute of Neurosciences, Budapest, Hungary
| | - David Vale
- 15 Neuravi Thromboembolic Initiative, Neuravi Ltd, Galway, Ireland
| | | | | | - Werner Hacke
- 31 Department of Neurology, University Hospital Heidelberg, Ruprecht-Karls University, Heidelberg, Germany
| | - David S Liebeskind
- 32 Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, California, USA
| | | |
Collapse
|
40
|
Liebeskind DS, De Meyer SF, Andersson T, Baxter B, Bendszus M, Brouwer P, Brinjikji W, Campbell B, Costalat V, Dávalos A, Demchuk A, Dippel D, Fiehler J, Fischer U, Gilvarry M, Gounis M, Gralla J, Jansen O, Jovin T, Kallmes D, Khatri P, Lees K, López-Cancio E, Majoie C, Marquering H, Narata AP, Nogueira R, Ringleb P, Siddiqui A, Szikora I, Vale D, von Kummer R, Yoo A, Hacke W. Analyses of thrombi in cerebral arteries with endovascular thrombectomy for acute ischemic stroke: A consensus statement. J Stroke Cerebrovasc Dis 2017. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
41
|
Spaander FH, Zinkstok SM, Baharoglu IM, Gensicke H, Polymeris A, Traenka C, Hametner C, Ringleb P, Curtze S, Martinez-Majander N, Aarnio K, Nolte CH, Scheitz JF, Leys D, Hochart A, Padjen V, Kägi G, Pezzini A, Michel P, Bill O, Zini A, Engelter ST, Nederkoorn PJ. Sex Differences and Functional Outcome After Intravenous Thrombolysis. Stroke 2017; 48:699-703. [DOI: 10.1161/strokeaha.116.014739] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Women have a worse outcome after stroke compared with men, although in intravenous thrombolysis (IVT)–treated patients, women seem to benefit more. Besides sex differences, age has also a possible effect on functional outcome. The interaction of sex on the functional outcome in IVT-treated patients in relation to age remains complex. The purpose of this study was to compare outcome after IVT between women and men with regard to age in a large multicenter European cohort reflecting daily clinical practice of acute stroke care.
Methods—
Data were obtained from IVT registries of 12 European tertiary hospitals. The primary outcome was poor functional outcome, defined as a modified Rankin scale score of 3 to 6 at 3 months. We stratified outcome by age in decades. Safety measures were symptomatic intracranial hemorrhage and mortality at 3 months.
Results—
In this cohort, 9495 patients were treated with IVT, and 4170 (43.9%) were women with a mean age of 71.9 years. After adjustments for baseline differences, female sex remained associated with poor functional outcome (odds ratio, 1.15; 95% confidence interval, 1.02–1.31). There was no association between sex and functional outcome when data were stratified by age. Symptomatic intracranial hemorrhage rate was similar in both sexes (adjusted odds ratio, 0.93; 95% confidence interval, 0.73–1.19), whereas mortality was lower among women (adjusted odds ratio, 0.83; 95% confidence interval, 0.70–0.99).
Conclusions—
In this large cohort of IVT-treated patients, women more often had poor functional outcome compared with men. This difference was not dependent on age.
Collapse
Affiliation(s)
- Fianne H. Spaander
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Sanne M. Zinkstok
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Irem M. Baharoglu
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Henrik Gensicke
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Alexandros Polymeris
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Christopher Traenka
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Christian Hametner
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Peter Ringleb
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Sami Curtze
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Nicolas Martinez-Majander
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Karoliina Aarnio
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Christian H. Nolte
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Jan F. Scheitz
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Didier Leys
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Anais Hochart
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Visnja Padjen
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Georg Kägi
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Alessandro Pezzini
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Patrik Michel
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Olivier Bill
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Andrea Zini
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Stefan T. Engelter
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| | - Paul J. Nederkoorn
- From the Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (F.H.S., S.M.Z., I.M.B., P.J.N.); Stroke Center and Department of Neurology, University Hospital Basel, Switzerland (H.G., A.P., C.T., S.T.E.); Department of Neurology, University Hospital Heidelberg, Germany (C.H., P.R.); Department of Neurology, Helsinki University Central Hospital, Finland (S.C., N.M.-M., K.A.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Germany
| |
Collapse
|
42
|
Möhlenbruch M, Pfaff J, Schönenberger S, Nagel S, Bösel J, Herweh C, Ringleb P, Bendszus M, Stampfl S. Endovascular Stroke Treatment of Nonagenarians. AJNR Am J Neuroradiol 2016; 38:299-303. [PMID: 27789451 DOI: 10.3174/ajnr.a4976] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/19/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although endovascular treatment has become a standard therapy in patients with acute stroke, the benefit for very old patients remains uncertain. The purpose of this study was the evaluation of procedural and outcome data of patients ≥90 years undergoing endovascular stroke treatment. MATERIALS AND METHODS We retrospectively analyzed prospectively collected data of patients ≥90 years in whom endovascular stroke treatment was performed between January 2011 and January 2016. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS, prestroke mRS), at discharge (NIHSS), and after 3 months (mRS). RESULTS Twenty-nine patients met the inclusion criteria for this analysis. The median prestroke mRS was 2. Successful recanalization (TICI ≥ 2b) was achieved in 22 patients (75.9%). In 9 patients, an NIHSS improvement ≥ 10 points was noted between admission and discharge. After 3 months, 17.2% of the patients had an mRS of 0-2 or exhibited prestroke mRS, and 24.1% achieved mRS 0-3. Mortality rate was 44.8%. There was only 1 minor procedure-related complication (small SAH without clinical sequelae). CONCLUSIONS Despite high mortality rates and only moderate overall outcome, 17.2% of the patients achieved mRS 0-2 or prestroke mRS, and no serious procedure-related complications occurred. Therefore, very high age should not per se be an exclusion criterion for endovascular stroke treatment.
Collapse
Affiliation(s)
- M Möhlenbruch
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - J Pfaff
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - S Schönenberger
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - S Nagel
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - J Bösel
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - P Ringleb
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - S Stampfl
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| |
Collapse
|
43
|
Eckstein HH, Reiff T, Ringleb P, Jansen O, Mansmann U, Hacke W. SPACE-2: A Missed Opportunity to Compare Carotid Endarterectomy, Carotid Stenting, and Best Medical Treatment in Patients with Asymptomatic Carotid Stenoses. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2016.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
44
|
Gumbinger C, Reuter B, Hacke W, Sauer T, Bruder I, Diehm C, Wiethölter H, Schoser K, Daffertshofer M, Neumaier S, Drewitz E, Rode S, Kern R, Hennerici MG, Stock C, Ringleb P. Restriction of therapy mainly explains lower thrombolysis rates in reduced stroke service levels. Neurology 2016; 86:1975-83. [PMID: 27164674 DOI: 10.1212/wnl.0000000000002695] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/11/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the influence of preexisting disabilities, age, and stroke service level on standardized IV thrombolysis (IVT) rates in acute ischemic stroke (AIS). METHODS We investigated standardized IVT rates in a retrospective registry-based study in 36,901 patients with AIS from the federal German state Baden-Wuerttemberg over a 5-year period. Patients admitted within 4.5 hours after stroke onset were selected. Factors associated with IVT rates (patient-level factors and stroke service level) were assessed using robust Poisson regression modeling. Interactions between factors were considered to estimate risk-adjusted mortality rates and potential IVT rates by service level (with stroke centers as benchmark). RESULTS Overall, 10,499 patients (28.5%) received IVT. The IVT rate declined with service level from 44.0% (stroke center) to 13.1% (hospitals without stroke unit [SU]). Especially patients >80 years of age and with preexisting disabilities had a lower chance of being treated with IVT at lower stroke service levels. Interactions between stroke service level and age group, preexisting disabilities, and stroke severity (all p < 0.0001) were observed. High IVT rates seemed not to increase mortality. Estimated potential IVT rates ranged between 41.9% and 44.6% depending on stroke service level. CONCLUSIONS Differences in IVT rates among stroke service levels were mainly explained by differences administering IVT to older patients and patients with preexisting disabilities. This indicates considerable further potential to increase IVT rates. Our findings support guideline recommendations to admit acute stroke patients to SUs.
Collapse
Affiliation(s)
- Christoph Gumbinger
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
| | - Björn Reuter
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Werner Hacke
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Tamara Sauer
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Ingo Bruder
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Curt Diehm
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Horst Wiethölter
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Karin Schoser
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Michael Daffertshofer
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Stephan Neumaier
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Elke Drewitz
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Susanne Rode
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Rolf Kern
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Michael G Hennerici
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Christian Stock
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| | - Peter Ringleb
- From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany
| |
Collapse
|
45
|
Eckstein HH, Reiff T, Ringleb P, Jansen O, Mansmann U, Hacke W. SPACE-2: A Missed Opportunity to Compare Carotid Endarterectomy, Carotid Stenting, and Best Medical Treatment in Patients with Asymptomatic Carotid Stenoses. Eur J Vasc Endovasc Surg 2016; 51:761-5. [PMID: 27085660 DOI: 10.1016/j.ejvs.2016.02.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/08/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Because of recent advances in best medical treatment (BMT), it is currently unclear whether any additional surgical or endovascular interventions confer additional benefit, in terms of preventing late ipsilateral carotid territory ischemic stroke in asymptomatic patients with significant carotid stenoses. The aim was to compare the stroke-preventive effects of BMT alone, with that of BMT in combination with carotid endarterectomy (CEA) or carotid artery stenting (CAS) in patients with high grade asymptomatic extracranial carotid artery stenosis. METHODS SPACE-2 was planned as a three-armed, randomized controlled trial (BMT alone vs. CEA plus BMT vs. CAS plus BMT, ISRCTN 78592017). However, because of slow patient recruitment, the three-arm study design was amended (July 2013) to become two parallel randomized studies (BMT alone vs. CEA plus BMT, and BMT alone vs. CAS plus BMT). RESULTS The change in study design did not lead to any significant increase in patient recruitment, and trial recruitment ceased after recruiting 513 patients over a 5 year period (CEA vs. BMT (n = 203); CAS vs. BMT (n = 197), and BMT alone (n = 113)). The 30 day rate of death/stroke was 1.97% for patients undergoing CEA, and 2.54% for patients undergoing CAS. No strokes or deaths occurred in the first 30 days after randomization in patients randomized to BMT. There were several potential reasons for the low recruitment rates into SPACE-2, including the ability for referring doctors to refer their patients directly for CEA or CAS outwith the trial, an inability to convince patients (who had come "mentally prepared" that an intervention was necessary) to accept BMT, and other economic constraints. CONCLUSIONS Because of slow recruitment rates, SPACE-2 had to be stopped after randomizing only 513 patients. The German Research Foundation will provide continued funding to enable follow up of all recruited patients, and it is also planned to include these data in any future meta-analysis prepared by the Carotid Stenosis Trialists Collaboration.
Collapse
Affiliation(s)
- H-H Eckstein
- Department of Vascular and Endovascular Surgery, Technical University of Munich, Munich, Germany
| | - T Reiff
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - O Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany
| | - U Mansmann
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig Maximilian University Munich, Munich, Germany
| | - W Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | | |
Collapse
|
46
|
Kernan WN, Viscoli CM, Furie KL, Young LH, Inzucchi SE, Gorman M, Guarino PD, Lovejoy AM, Peduzzi PN, Conwit R, Brass LM, Schwartz GG, Adams HP, Berger L, Carolei A, Clark W, Coull B, Ford GA, Kleindorfer D, O'Leary JR, Parsons MW, Ringleb P, Sen S, Spence JD, Tanne D, Wang D, Winder TR. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. N Engl J Med 2016; 374:1321-31. [PMID: 26886418 PMCID: PMC4887756 DOI: 10.1056/nejmoa1506930] [Citation(s) in RCA: 719] [Impact Index Per Article: 89.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease. METHODS In this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction. RESULTS By 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003). CONCLUSIONS In this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.).
Collapse
Affiliation(s)
- Walter N Kernan
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Catherine M Viscoli
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Karen L Furie
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Lawrence H Young
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Silvio E Inzucchi
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Mark Gorman
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Peter D Guarino
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Anne M Lovejoy
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Peter N Peduzzi
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Robin Conwit
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Lawrence M Brass
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Gregory G Schwartz
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Harold P Adams
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Leo Berger
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Antonio Carolei
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Wayne Clark
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Bruce Coull
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Gary A Ford
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Dawn Kleindorfer
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - John R O'Leary
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Mark W Parsons
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Peter Ringleb
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Souvik Sen
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - J David Spence
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - David Tanne
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - David Wang
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Toni R Winder
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| |
Collapse
|
47
|
Affiliation(s)
- P. Ringleb
- Neurologische Universitätsklinik Heidelberg
| | - G. Hamann
- Klinik für Neurologie und Neurologische Rehabilitation, Bezirkskrankenhaus Günzburg
| | - J. Röther
- Neurologische Abteilung, Asklepios Klinik Hamburg Altona
| | - O. Jansen
- Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Kiel
| | - C. Groden
- Abteilung für Neuroradiologie, Universitätsklinikum Mannheim
| | - R. Veltkamp
- Department of Stroke Medicine, Imperial College London
| |
Collapse
|
48
|
Gensicke H, Strbian D, Zinkstok SM, Scheitz JF, Bill O, Hametner C, Moulin S, Zini A, Kägi G, Pezzini A, Padjen V, Béjot Y, Corbiere S, Zonneveld TP, Seiffge DJ, Roos YB, Traenka C, Putaala J, Peters N, Bonati LH, Curtze S, Erdur H, Sibolt G, Koch P, Vandelli L, Ringleb P, Leys D, Cordonnier C, Michel P, Nolte CH, Lyrer PA, Tatlisumak T, Nederkoorn PJ, Engelter ST. Intravenous Thrombolysis in Patients Dependent on the Daily Help of Others Before Stroke. Stroke 2016; 47:450-6. [DOI: 10.1161/strokeaha.115.011674] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We compared outcome and complications in patients with stroke treated with intravenous thrombolysis (IVT) who could not live alone without help of another person before stroke (dependent patients) versus independent ones.
Methods—
In a multicenter IVT-register–based cohort study, we compared previously dependent (prestroke modified Rankin Scale score, 3–5) versus independent (prestroke modified Rankin Scale score, 0–2) patients. Outcome measures were poor 3-month outcome (not reaching at least prestroke modified Rankin Scale [dependent patients]; modified Rankin Scale score of 3–6 [independent patients]), death, and symptomatic intracranial hemorrhage. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (OR [95% confidence interval]) were calculated.
Results—
Among 7430 IVT-treated patients, 489 (6.6%) were dependent and 6941 (93.4%) were independent. Previous stroke, dementia, heart, and bone diseases were the most common causes of preexisting dependency. Dependent patients were more likely to die (OR
unadjusted
, 4.55 [3.74–5.53]; OR
adjusted
, 2.19 [1.70–2.84]). Symptomatic intracranial hemorrhage occurred equally frequent (4.8% versus 4.5%). Poor outcome was more frequent in dependent (60.5%) than in independent (39.6%) patients, but the adjusted ORs were similar (OR
adjusted
, 0.95 [0.75–1.21]). Among survivors, the proportion of patients with poor outcome did not differ (35.7% versus 31.3%). After adjustment for age and stroke severity, the odds of poor outcome were lower in dependent patients (OR
adjusted
, 0.64 [0.49–0.84]).
Conclusions—
IVT-treated stroke patients who were dependent on the daily help of others before stroke carry a higher mortality risk than previously independent patients. The risk of symptomatic intracranial hemorrhage and the likelihood of poor outcome were not independently influenced by previous dependency. Among survivors, poor outcome was avoided at least as effectively in previously dependent patients. Thus, withholding IVT in previously dependent patients might not be justified.
Collapse
Affiliation(s)
- Henrik Gensicke
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Daniel Strbian
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Sanne M. Zinkstok
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Jan F. Scheitz
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Olivier Bill
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Christian Hametner
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Solène Moulin
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Andrea Zini
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Georg Kägi
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Alessandro Pezzini
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Visnja Padjen
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Yannick Béjot
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Sydney Corbiere
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Thomas P. Zonneveld
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - David J. Seiffge
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Yvo B. Roos
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Christopher Traenka
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Jukka Putaala
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Nils Peters
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Leo H. Bonati
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Sami Curtze
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Hebun Erdur
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Gerli Sibolt
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Peter Koch
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Laura Vandelli
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Peter Ringleb
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Didier Leys
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Charlotte Cordonnier
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Patrik Michel
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Christian H. Nolte
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Philippe A. Lyrer
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Turgut Tatlisumak
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Paul J. Nederkoorn
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | - Stefan T. Engelter
- From the Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland (H.G., S.C., D.J.S., C.T., N.P., L.H.B., P.A.L., S.T.E.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (D.S., J.P., S.C., G.S., T.T.); Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands (S.M.Z., T.P.Z., Y.B.R., P.J.N.); Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany (J.F.S., H.E., P
| | | |
Collapse
|
49
|
Abbott AL, Paraskevas KI, Kakkos SK, Golledge J, Eckstein HH, Diaz-Sandoval LJ, Cao L, Fu Q, Wijeratne T, Leung TW, Montero-Baker M, Lee BC, Pircher S, Bosch M, Dennekamp M, Ringleb P. Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis. Stroke 2015; 46:3288-301. [PMID: 26451020 DOI: 10.1161/strokeaha.115.003390] [Citation(s) in RCA: 188] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 08/31/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. METHODS We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. RESULTS Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86%) endorsed CEA (recommended it should or may be provided) for ≈50% to 99% average-surgical-risk asymptomatic carotid artery stenosis, 17 (61%) endorsed CAS, 8 (29%) opposed CAS, and 1 (4%) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46%). Thirty-one of 33 guidelines (94%) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ≈50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 19 (58%) endorsed CAS and 9 (27%) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82%). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. CONCLUSIONS This systematic review has identified many opportunities to modernize and otherwise improve carotid stenosis management guidelines.
Collapse
Affiliation(s)
- Anne L Abbott
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.).
| | - Kosmas I Paraskevas
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Stavros K Kakkos
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Jonathan Golledge
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Hans-Henning Eckstein
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Larry J Diaz-Sandoval
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Longxing Cao
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Qiang Fu
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Tissa Wijeratne
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Thomas W Leung
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Miguel Montero-Baker
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Byung-Chul Lee
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Sabine Pircher
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Marije Bosch
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Martine Dennekamp
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| | - Peter Ringleb
- From the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.L.A, M.D.), Department of Surgery, Central Clinical School (M.B.), Monash University, Melbourne, Victoria, Australia; Neurology Department, The Alfred Hospital, Prahran, Victoria, Australia (A.L.A.); Department of Cardiovascular Sciences, St. George'sVascular Institute, St George's Hospital, London, United Kingdom (K.I.P.); Department of Vascular Surgery, University of Patras, Patras, Greece (S.K.K.); Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia (J.G.); Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia (J.G.); Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany (H.-H.E.); Department of Medicine, Michigan State University, Metro Health Hospital, Grand Rapids, MI (L.J.D.-S.); Cardiology Department, Xiamen Cardiovascular Hospital, Xiamen, Fujian, China (L.C.); Center for Cardiology Intervention Treatment, Department of Cardiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China (Q.F.); Stroke Unit, Department of Neurology, Western Hospital, University of Melbourne, Footscray, Melbourne, Victoria, Australia (T.W.); Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China (T.W.L.); Department of Vascular Surgery, University of Arizona and Pima Vascular Group, Tucson (M.M.-B.); Department of Neurology, Hallym Neurological Institute, Hallym University, Sacred Heart Hospital, Seoul, South Korea (B.-C.L.); Centre for Health and Social Research, Faculty of Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia (S.P.); and Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.R.)
| |
Collapse
|
50
|
Fisch U, von Felten S, Roubin G, Mali W, Jansen O, Howard G, Fraederich G, Chatellier G, Becquemin J, Algra A, Ringleb P, Mas J, Brown M, Brott T, Bonati L. Low Risk of Stroke or Death among Patients with Recently Symptomatic Carotid Stenosis Awaiting Revascularization—A Pooled Analysis of Recent Randomized Trials. J Neurol Surg A Cent Eur Neurosurg 2015. [DOI: 10.1055/s-0035-1564535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|