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Broocks G, McDonough RV, Bechstein M, Klapproth S, Faizy TD, Schön G, Kniep HC, Bester M, Hanning U, Kemmling A, Zeleñák K, Fiehler J, Meyer L. Thrombectomy in Patients With Ischemic Stroke Without Salvageable Tissue on CT Perfusion. Stroke 2024; 55:1317-1325. [PMID: 38572635 DOI: 10.1161/strokeaha.123.044916] [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: 08/21/2023] [Accepted: 02/22/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging is regularly used to guide patient selection for mechanical thrombectomy (MT). However, the effect of MT in patients without salvageable tissue on CTP has not been investigated. The purpose of this study was to assess the effect of MT in patients with stroke without perfusion mismatch profiles. METHODS This observational study analyzed patients with ischemic stroke consecutively treated between March 1, 2015, and January 31, 2022, triaged by multimodal-computed tomography undergoing MT. CTP lesion-core mismatch profiles were defined using a mismatch volume/ratio of ≥10 mL/1.2, respectively. The primary end point was the rate of functional independence at 90 days, defined as the modified Rankin Scale score of 0 to 2. Recanalization was evaluated with the modified Thrombolysis in Cerebral Infarction scale. The effect of baseline variables on functional outcome was assessed using multivariable logistic regression analysis. Outcomes of patients with and without CTP-mismatch profiles were compared using 1:1 propensity score matching. RESULTS Of 724 patients who met the inclusion criteria of this retrospective observational study, 110 (15%) patients had no CTP mismatch and were analyzed. The median age was 74 (interquartile range, 62-80) years and 53% were women. Successful recanalization (modified Thrombolysis in Cerebral Infarction score, ≥2b) was achieved in 66% (73) and associated with functional independence at 90 days (adjusted odds ratio, 7.33 [95% CI, 1.22-43.70]; P=0.03). A significant interaction was observed between recanalization and age, as well as the extent of infarction, indicating MT to be most effective in patients <70 years and with a baseline Alberta Stroke Program Early Computed Tomography Score range between 3 and 7. These findings remained stable after propensity score matching, analyzing 152 matched pairs with similar rates of functional independence between patients with and without CTP-mismatch profiles (17% versus 23%; P=0.42). CONCLUSIONS In patients without CTP-mismatch profiles defined according to the EXTEND (Extending the Time for Thrombolysis in Emergency Neurological Deficits) criteria, recanalization was associated with improved functional outcomes. This effect was associated with baseline Alberta Stroke Program Early Computed Tomography Score and age, but not with the time from onset to imaging.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany (G.B.)
| | | | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology (G.S.) University Medical Center Hamburg-Eppendorf, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - André Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Marburg, Marburg, Germany (A.K.)
| | - Kamil Zeleñák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia (K.Z.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
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Klapproth S, Meyer L, Kniep H, Bechstein M, Kyselyova A, Hanning U, Schön G, Rimmele L, Fiehler J, Broocks G. Effect of short- versus long-term serum glucose levels on early ischemic water homeostasis and functional outcome in patients with large vessel occlusion stroke. Eur J Neurol 2024; 31:e16166. [PMID: 38015448 DOI: 10.1111/ene.16166] [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: 08/25/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND PURPOSE In ischemic stroke, the impact of short- versus long-term blood glucose level (BGL) on early lesion pathophysiology and functional outcome has not been assessed. The purpose of this study was to directly compare the effect of long-term blood glucose (glycated hemoglobin [HbA1c]) versus serum BGL on early edema formation and functional outcome. METHODS Anterior circulation ischemic stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) on admission were analyzed. Endpoints were early ischemic cerebral edema, measured by quantitative net water uptake (NWU) on initial CT and functional independence at Day 90. RESULTS A total of 345 patients were included. Patients with functional independence had significantly lower baseline NWU (3.1% vs. 8.3%; p < 0.001) and lower BGL (113 vs. 123 mg/dL; p < 0.001) than those without functional independence, while HbA1c levels did not differ significantly (5.7% vs. 5.8%; p = 0.15). A significant association was found for NWU and BGL (ß = 0.02, 95% confidence interval [CI] 0.006-0.03; p = 0.002), but not for HbA1c and NWU (ß = -0.16, 95% CI -0.53-0.21; p = 0.39). Mediation analysis showed that 67% of the effect of BGL on functional outcome was mediated by early edema formation. CONCLUSION Aggravated early edema and worse functional outcome was associated with elevated short-term serum BGL, but not with HbA1c levels. Hence, the link between short-term BGL and early edema development might be used as a target for adjuvant therapy in patients with ischemic stroke.
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Affiliation(s)
- Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Kyselyova
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leander Rimmele
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Broocks G, Kemmling A, Kniep H, Meyer L, Faizy TD, Hanning U, Rimmele LD, Klapproth S, Schön G, Zeleňák K, Fiehler J, McDonough R. Edema Reduction versus Penumbra Salvage: Investigating Treatment Effects of Mechanical Thrombectomy in Ischemic Stroke. Ann Neurol 2023. [PMID: 37726933 DOI: 10.1002/ana.26802] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE Mechanical thrombectomy (MT) is of benefit to patients with ischemic stroke; however, the effect of recanalization on lesion pathophysiology is not yet well understood. The aim of this study was to quantitatively assess how the effect of vessel recanalization on clinical outcome is mediated by edema reduction versus penumbra salvage. METHODS Consecutive analysis was made of anterior circulation ischemic stroke patients triaged by multimodal computed tomography (CT) undergoing MT. Edema reduction was defined using the difference of quantitative net water uptake (NWU) determined on baseline and follow-up CT (∆NWU). Penumbra salvage volume (PSV) was defined as the difference between admission penumbra and net infarct growth volumes to follow-up. Mediation analyses were performed with vessel recanalization as independent variable (modified Thrombolysis in Cerebral Infarction ≥ 2b) and ∆NWU/PSV as mediator variables. Modified Rankin Scale scores at 90 days served as endpoint. RESULTS Of 422 included patients, 321 (76%) achieved successful recanalization. The median ∆NWU was 6.8% (interquartile range [IQR] = 3.9-10.4), and the median PSV was 66ml (IQR = 8-124). ∆NWU, PSV, and recanalization were significantly associated with functional outcome in logistic regression analysis. ∆NWU and PSV partially mediated the relationship between recanalization and outcome. Sixty-six percent of the relationship between recanalization and functional outcome could be explained by treatment-induced edema reduction, whereas 22% was mediated by PSV (p < 0.0001). INTERPRETATION Compared to penumbra salvage, edema reduction was a stronger mediator of the effect of recanalization on functional outcome. Given the current trials on adjuvant neuroprotectants also targeting ischemic edema formation, combining reperfusion with antiedematous neuroprotectants may have synergistic effects resulting in better outcomes in patients with ischemic stroke. ANN NEUROL 2023.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leander D Rimmele
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
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