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Lima FO, Rocha FA, Silva HC, Puetz V, Dippel D, van den Wijngaard I, Majoie C, Yoo AJ, van Zwam W, de Lucena AF, Bandeira DDA, Arndt M, Barlinn K, Gerber JC, Langezaal LCM, Schonewille WJ, Pontes Neto OM, Dias FA, Martins SO, Mont’Alverne FJDA. Posterior circulation collaterals as predictors of outcome in basilar artery occlusion: a sub-analysis of the BASICS randomized trial. Front Neurol 2024; 15:1360335. [PMID: 38606280 PMCID: PMC11007200 DOI: 10.3389/fneur.2024.1360335] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction and purpose Basilar artery occlusion (BAO) is still one of the most devastating neurological conditions associated with high morbidity and mortality. In the present study, we aimed to assess the role of posterior circulation collaterals as predictors of outcome in the BASICS trial and to compare two grading systems (BATMAN score and PC-CS) in terms of prognostic value. Methods We performed a sub-analysis of the BASICS trial. Baseline clinical and imaging variables were analyzed. For the imaging analysis, baseline CT and CTA were analyzed by a central core lab. Only those patients with good or moderate quality of baseline CTA and with confirmed BAO were included. Multivariable binary logistic regression analysis was used to test the independent association of clinical and imaging characteristics with a favorable outcome at 3 months (defined as a modified Rankin Score of ≤3). ROC curve analysis was used to assess and compare accuracy between the two collateral grading systems. Results The mean age was 67.0 (±12.5) years, 196 (65.3%) patients were males and the median NIHSS was 21.5 (IQR 11-35). Median NCCT pc-ASPECTS was 10 (IQR10-10) and median collateral scores for BATMAN and PC-CS were 8 (IQR 7-9) and 7 (IQR 6-8) respectively. Collateral scores were associated with favorable outcome at 3 months for both BATMAN and PC-CS but only with a modest accuracy on ROC curve analysis (AUC 0.62, 95% CI [0.55-0.69] and 0.67, 95% CI [0.60-0.74] respectively). Age (OR 0.97, 95% CI [0.95-1.00]), NIHSS (OR 0.91, 95% CI [0.89-0.94]) and collateral score (PC-CS - OR 1.2495% CI [1.02-1.51]) were independently associated with clinical outcome. Conclusion The two collateral grading systems presented modest prognostic accuracy. Only the PC-CS was independently associated with a favorable outcome at 3 months.
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Affiliation(s)
- Fabricio O. Lima
- Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Felipe A. Rocha
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Henrique C. Silva
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Volker Puetz
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Diederik Dippel
- Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | | | | | - Wim van Zwam
- Interventional Radiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Adson F. de Lucena
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | | | - Martin Arndt
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Johannes C. Gerber
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
- Institute of Neuroradiology, Dresden Neurovascular Center, Universitätsklinik Dresden, Dresden, Germany
| | | | | | - Octávio M. Pontes Neto
- Stroke Service, Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, Brazil
| | - Francisco Antunes Dias
- Stroke Service, Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, Brazil
| | - Sheila Ouriques Martins
- Department of Neurology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Kaesmacher J, Cavalcante F, Kappelhof M, Treurniet KM, Rinkel L, Liu J, Yan B, Zi W, Kimura K, Eker OF, Zhang Y, Piechowiak EI, van Zwam W, Liu S, Strbian D, Uyttenboogaart M, Dobrocky T, Miao Z, Suzuki K, Zhang L, van Oostenbrugge R, Meinel TR, Guo C, Seiffge D, Yin C, Bütikofer L, Lingsma H, Nieboer D, Yang P, Mitchell P, Majoie C, Fischer U, Roos Y, Gralla J. Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis. JAMA 2024; 331:764-777. [PMID: 38324409 PMCID: PMC10851137 DOI: 10.1001/jama.2024.0589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
Importance The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke declines with longer time from symptom onset, but it is not known whether a similar time dependency exists for IVT followed by thrombectomy. Objective To determine whether the benefit associated with IVT plus thrombectomy vs thrombectomy alone decreases with treatment time from symptom onset. Design, Setting, and Participants Individual participant data meta-analysis from 6 randomized clinical trials comparing IVT plus thrombectomy vs thrombectomy alone. Enrollment was between January 2017 and July 2021 at 190 sites in 15 countries. All participants were eligible for IVT and thrombectomy and presented directly at thrombectomy-capable stroke centers (n = 2334). For this meta-analysis, only patients with an anterior circulation large-vessel occlusion were included (n = 2313). Exposure Interval from stroke symptom onset to expected administration of IVT and treatment with IVT plus thrombectomy vs thrombectomy alone. Main Outcomes and Measures The primary outcome analysis tested whether the association between the allocated treatment (IVT plus thrombectomy vs thrombectomy alone) and disability at 90 days (7-level modified Rankin Scale [mRS] score range, 0 [no symptoms] to 6 [death]; minimal clinically important difference for the rates of mRS scores of 0-2: 1.3%) varied with times from symptom onset to expected administration of IVT. Results In 2313 participants (1160 in IVT plus thrombectomy group vs 1153 in thrombectomy alone group; median age, 71 [IQR, 62 to 78] years; 44.3% were female), the median time from symptom onset to expected administration of IVT was 2 hours 28 minutes (IQR, 1 hour 46 minutes to 3 hours 17 minutes). There was a statistically significant interaction between the time from symptom onset to expected administration of IVT and the association of allocated treatment with functional outcomes (ratio of adjusted common odds ratio [OR] per 1-hour delay, 0.84 [95% CI, 0.72 to 0.97], P = .02 for interaction). The benefit of IVT plus thrombectomy decreased with longer times from symptom onset to expected administration of IVT (adjusted common OR for a 1-step mRS score shift toward improvement, 1.49 [95% CI, 1.13 to 1.96] at 1 hour, 1.25 [95% CI, 1.04 to 1.49] at 2 hours, and 1.04 [95% CI, 0.88 to 1.23] at 3 hours). For a mRS score of 0, 1, or 2, the predicted absolute risk difference was 9% (95% CI, 3% to 16%) at 1 hour, 5% (95% CI, 1% to 9%) at 2 hours, and 1% (95% CI, -3% to 5%) at 3 hours. After 2 hours 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant and the point estimate crossed the null association at 3 hours 14 minutes. Conclusions and Relevance In patients presenting at thrombectomy-capable stroke centers, the benefit associated with IVT plus thrombectomy vs thrombectomy alone was time dependent and statistically significant only if the time from symptom onset to expected administration of IVT was short.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Kilian M. Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden Medical Center, the Hague, the Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Omer F. Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sheng Liu
- Department of Radiology, Jiangsu Provincial People’s Hospital of Nanjing Medical University, Nanjing, China
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Congguo Yin
- Department of Neurology, Hangzhou First People’s Hospital of Zhejiang University, Hangzhou, China
| | | | - Hester Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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Mojtahedi M, Bruggeman AE, van Voorst H, Ponomareva E, Kappelhof M, van der Lugt A, Hoving JW, Dutra BG, Dippel D, Cavalcante F, Yo L, Coutinho J, Brouwer J, Treurniet K, Tolhuisen ML, LeCouffe N, Arrarte Terreros N, Konduri PR, van Zwam W, Roos Y, Majoie CBLM, Emmer BJ, Marquering HA. Value of Automatically Derived Full Thrombus Characteristics: An Explorative Study of Their Associations with Outcomes in Ischemic Stroke Patients. J Clin Med 2024; 13:1388. [PMID: 38592252 PMCID: PMC10932251 DOI: 10.3390/jcm13051388] [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: 01/18/2024] [Revised: 02/17/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: For acute ischemic strokes caused by large vessel occlusion, manually assessed thrombus volume and perviousness have been associated with treatment outcomes. However, the manual assessment of these characteristics is time-consuming and subject to inter-observer bias. Alternatively, a recently introduced fully automated deep learning-based algorithm can be used to consistently estimate full thrombus characteristics. Here, we exploratively assess the value of these novel biomarkers in terms of their association with stroke outcomes. (2) Methods: We studied two applications of automated full thrombus characterization as follows: one in a randomized trial, MR CLEAN-NO IV (n = 314), and another in a Dutch nationwide registry, MR CLEAN Registry (n = 1839). We used an automatic pipeline to determine the thrombus volume, perviousness, density, and heterogeneity. We assessed their relationship with the functional outcome defined as the modified Rankin Scale (mRS) at 90 days and two technical success measures as follows: successful final reperfusion, which is defined as an eTICI score of 2b-3, and successful first-pass reperfusion (FPS). (3) Results: Higher perviousness was significantly related to a better mRS in both MR CLEAN-NO IV and the MR CLEAN Registry. A lower thrombus volume and lower heterogeneity were only significantly related to better mRS scores in the MR CLEAN Registry. Only lower thrombus heterogeneity was significantly related to technical success; it was significantly related to a higher chance of FPS in the MR CLEAN-NO IV trial (OR = 0.55, 95% CI: 0.31-0.98) and successful reperfusion in the MR CLEAN Registry (OR = 0.88, 95% CI: 0.78-0.99). (4) Conclusions: Thrombus characteristics derived from automatic entire thrombus segmentations are significantly related to stroke outcomes.
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Affiliation(s)
- Mahsa Mojtahedi
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.v.V.); (M.L.T.); (P.R.K.); (H.A.M.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Agnetha E. Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Henk van Voorst
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.v.V.); (M.L.T.); (P.R.K.); (H.A.M.)
| | | | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, 3015 GD Rotterdam, The Netherlands;
| | - Jan W. Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Bruna G. Dutra
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Diederik Dippel
- Department of Neurology, Erasmus MC UMC, 3015 GD Rotterdam, The Netherlands;
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Lonneke Yo
- Department of Radiology, Catharina Ziekenhuis, 5623 EJ Eindhoven, The Netherlands
| | - Jonathan Coutinho
- Department of Neurology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (J.C.); (J.B.); (Y.R.)
| | - Josje Brouwer
- Department of Neurology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (J.C.); (J.B.); (Y.R.)
| | - Kilian Treurniet
- Research Bureau of Radiology and Nuclear Medicine, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands;
- Department of Radiology, The Hague Medical Center, 2262 BA The Hague, The Netherlands
| | - Manon L. Tolhuisen
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.v.V.); (M.L.T.); (P.R.K.); (H.A.M.)
| | - Natalie LeCouffe
- Department of Neurology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (J.C.); (J.B.); (Y.R.)
| | - Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.v.V.); (M.L.T.); (P.R.K.); (H.A.M.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Praneeta R. Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.v.V.); (M.L.T.); (P.R.K.); (H.A.M.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht UMC, Cardiovascular Research Institute Maastricht (CARIM), 6229 HX Maastricht, The Netherlands;
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (J.C.); (J.B.); (Y.R.)
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
| | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.v.V.); (M.L.T.); (P.R.K.); (H.A.M.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (A.E.B.); (M.K.); (J.W.H.); (B.G.D.); (F.C.); (C.B.L.M.M.); (B.J.E.)
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4
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van Linschoten RCA, Amini M, van Leeuwen N, Eijkenaar F, den Hartog SJ, Nederkoorn PJ, Hofmeijer J, Emmer BJ, Postma AA, van Zwam W, Roozenbeek B, Dippel D, Lingsma HF. Handling missing values in the analysis of between-hospital differences in ordinal and dichotomous outcomes: a simulation study. BMJ Qual Saf 2023; 32:742-749. [PMID: 37734955 DOI: 10.1136/bmjqs-2023-016387] [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: 05/30/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023]
Abstract
Missing data are frequently encountered in registries that are used to compare performance across hospitals. The most appropriate method for handling missing data when analysing differences in outcomes between hospitals with a generalised linear mixed model is unclear. We aimed to compare methods for handling missing data when comparing hospitals on ordinal and dichotomous outcomes. We performed a simulation study using data from the Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands (MR CLEAN) Registry, a prospective cohort study in 17 hospitals performing endovascular therapy for ischaemic stroke in the Netherlands. The investigated methods for handling missing data, both case-mix adjustment variables and outcomes, were complete case analysis, single imputation, multiple imputation, single imputation with deletion of imputed outcomes and multiple imputation with deletion of imputed outcomes. Data were generated as missing completely at random (MCAR), missing at random and missing not at random (MNAR) in three scenarios: (1) 10% missing data in case-mix and outcome; (2) 40% missing data in case-mix and outcome; and (3) 40% missing data in case-mix and outcome with varying degree of missing data among hospitals. Bias and reliability of the methods were compared on the mean squared error (MSE, a summary measure combining bias and reliability) relative to the hospital effect estimates from the complete reference data set. For both the ordinal outcome (ie, the modified Rankin Scale) and a common dichotomised version thereof, all methods of handling missing data were biased, likely due to shrinkage of the random effects. The MSE of all methods was on average lowest under MCAR and with fewer missing data, and highest with more missing data and under MNAR. The 'multiple imputation, then deletion' method had the lowest MSE for both outcomes under all simulated patterns of missing data. Thus, when estimating hospital effects on ordinal and dichotomous outcomes in the presence of missing data, the least biased and most reliable method to handle these missing data is 'multiple imputation, then deletion'.
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Affiliation(s)
- Reinier C A van Linschoten
- Public Health, Erasmus MC, Rotterdam, Netherlands
- Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, Netherlands
- Department of Gastroenterology & Hepatology, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Frank Eijkenaar
- Erasmus School of Health Policy and Management, Erasmus Universiteit Rotterdam, Rotterdam, Netherlands
| | - Sanne J den Hartog
- Public Health, Erasmus MC, Rotterdam, Netherlands
- Neurology, Erasmus MC, Rotterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Netherlands
| | | | - Jeannette Hofmeijer
- Neurology, Rijnstate Hospital, Arnhem, Netherlands
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Bart J Emmer
- Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, Netherlands
| | - Alida A Postma
- Radiology and Nuclear Medicine, MUMC+, Maastricht, Netherlands
- School for Mental Health and Sciences, Maastricht University, Maastricht, Netherlands
| | - Wim van Zwam
- Radiology and Nuclear Medicine, MUMC+, Maastricht, Netherlands
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5
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Konduri P, Cavalcante F, van Voorst H, Rinkel L, Kappelhof M, van Kranendonk K, Treurniet K, Emmer B, Coutinho J, Wolff L, Hofmeijer J, Uyttenboogaart M, van Zwam W, Roos Y, Majoie C, Marquering H. Role of intravenous alteplase on late lesion growth and clinical outcome after stroke treatment. J Cereb Blood Flow Metab 2023; 43:116-125. [PMID: 37017421 PMCID: PMC10638991 DOI: 10.1177/0271678x231167755] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 01/24/2023] [Accepted: 03/03/2023] [Indexed: 04/06/2023]
Abstract
Several acute ischemic stroke mechanisms that cause lesion growth continue after treatment which is detrimental to long-term clinical outcome. The potential role of intravenous alteplase treatment (IVT), a standard in stroke care, in cessing the physiological processes causing post-treatment lesion development is understudied. We analyzed patients from the MR CLEAN-NO IV trial with good quality 24-hour and 1-week follow-up Non-Contrast CT scans. We delineated hypo- and hyper-dense regions on the scans as lesion. We performed univariable logistic and linear regression to estimate the influence of IVT on the presence (growth > 0 ml) and extent of late lesion growth. The association between late lesion growth and mRS was assessed using ordinal logistic regression. Interaction analysis was performed to evaluate the influence of IVT on this association. Of the 63/116 were randomized to included patients, IVT. Median growth was 8.4(-0.88-26) ml. IVT was not significantly associated with the presence (OR: 1.24 (0.57-2.74, p = 0.59) or extent (β = 5.1(-8.8-19), p = 0.47) of growth. Late lesion growth was associated with worse clinical outcome (aOR: 0.85(0.76-0.95), p < 0.01; per 10 ml). IVT did not influence this association (p = 0.18). We did not find evidence that IVT influences late lesion growth or the relationship between growth and worse clinical outcome. Therapies to reduce lesion development are necessary.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Henk van Voorst
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Katinka van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden MC, The Hague, The Netherlands
| | - Bart Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Jonathan Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Lennard Wolff
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Jeanette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - on behalf of the MR CLEAN-NO IV Trial Investigators (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands)
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden MC, The Hague, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
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6
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Amini M, Eijkenaar F, Lingsma HF, den Hartog SJ, Olthuis SGH, Martens J, van der Worp B, van Zwam W, van der Hoorn A, Roosendaal SD, Roozenbeek B, Dippel D, van Leeuwen N. Validity of Early Outcomes as Indicators for Comparing Hospitals on Quality of Stroke Care. J Am Heart Assoc 2023; 12:e027647. [PMID: 37042276 DOI: 10.1161/jaha.122.027647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Background Insight into outcome variation between hospitals could help to improve quality of care. We aimed to assess the validity of early outcomes as quality indicators for acute ischemic stroke care for patients treated with endovascular therapy (EVT). Methods and Results We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, a large multicenter prospective cohort study including 3279 patients with acute ischemic stroke undergoing EVT. Random effect linear and proportional odds regression were used to analyze the effect of case mix on between-hospital differences in 2 early outcomes: the National Institutes of Health Stroke Scale (NIHSS) score at 24 to 48 hours and the expanded thrombolysis in cerebral infarction score. Between-hospital variation in outcomes was assessed using the variance of random hospital effects (tau2). In addition, we estimated the correlation between hospitals' EVT-patient volume and (case-mix-adjusted) outcomes. Both early outcomes and case-mix characteristics varied significantly across hospitals. Between-hospital variation in the expanded thrombolysis in cerebral infarction score was not influenced by case-mix adjustment (tau 2=0.17 in both models). In contrast, for the NIHSS score at 24 to 48 hours, case-mix adjustment led to a decrease in variation between hospitals (tau 2 decreases from 0.19 to 0.17). Hospitals' EVT-patient volume was strongly correlated with higher expanded thrombolysis in cerebral infarction scores (r=0.48) and weakly with lower NIHSS score at 24 to 48 hours (r=0.15). Conclusions Between-hospital variation in NIHSS score at 24 to 48 hours is significantly influenced by case-mix but not by patient volume. In contrast, between-hospital variation in expanded thrombolysis in cerebral infarction score is strongly influenced by EVT-patient volume but not by case-mix. Both outcomes may be suitable for comparing hospitals on quality of care, provided that adequate adjustment for case-mix is applied for NIHSS score.
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Affiliation(s)
- Marzyeh Amini
- Department of Public Health Erasmus University Medical Center Rotterdam The Netherlands
| | - Frank Eijkenaar
- Erasmus School of Health Policy and Management Erasmus University Rotterdam Rotterdam The Netherlands
| | - Hester F Lingsma
- Department of Public Health Erasmus University Medical Center Rotterdam The Netherlands
| | - Sanne J den Hartog
- Department of Public Health Erasmus University Medical Center Rotterdam The Netherlands
- Department of Radiology and Nuclear Medicine Erasmus University Medical Center Rotterdam The Netherlands
- Department of Neurology Erasmus University Medical Center Rotterdam The Netherlands
| | - Susanne G H Olthuis
- Department of Neurology Maastricht University Medical Center and School for Cardiovascular Diseases Maastricht The Netherlands
| | - Jasper Martens
- Department of Radiology Rijnstate Arnhem The Netherlands
| | - Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Wim van Zwam
- Department of Neurology Maastricht University Medical Center and School for Cardiovascular Diseases Maastricht The Netherlands
- Department of Radiology and Nuclear Medicine Maastricht University Medical Center, Cardiovascular Research Institute Maastricht Maastricht The Netherlands
| | - Anouk van der Hoorn
- Department of Radiology, Medical Imaging Center University Medical Center Groningen Groningen The Netherlands
| | - Stefan D Roosendaal
- Department of Radiology and Nuclear Medicine Amsterdam University Medical Center Amsterdam The Netherlands
| | - Bob Roozenbeek
- Department of Radiology and Nuclear Medicine Erasmus University Medical Center Rotterdam The Netherlands
- Department of Neurology Erasmus University Medical Center Rotterdam The Netherlands
| | - Diederik Dippel
- Department of Neurology Erasmus University Medical Center Rotterdam The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health Erasmus University Medical Center Rotterdam The Netherlands
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7
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Su J, Li S, Wolff L, van Zwam W, Niessen WJ, van der Lugt A, van Walsum T. Deep reinforcement learning for cerebral anterior vessel tree extraction from 3D CTA images. Med Image Anal 2023; 84:102724. [PMID: 36525842 DOI: 10.1016/j.media.2022.102724] [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: 06/17/2022] [Revised: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
Extracting the cerebral anterior vessel tree of patients with an intracranial large vessel occlusion (LVO) is relevant to investigate potential biomarkers that can contribute to treatment decision making. The purpose of our work is to develop a method that can achieve this from routinely acquired computed tomography angiography (CTA) and computed tomography perfusion (CTP) images. To this end, we regard the anterior vessel tree as a set of bifurcations and connected centerlines. The method consists of a proximal policy optimization (PPO) based deep reinforcement learning (DRL) approach for tracking centerlines, a convolutional neural network based bifurcation detector, and a breadth-first vessel tree construction approach taking the tracking and bifurcation detection results as input. We experimentally determine the added values of various components of the tracker. Both DRL vessel tracking and CNN bifurcation detection were assessed in a cross validation experiment using 115 subjects. The anterior vessel tree formation was evaluated on an independent test set of 25 subjects, and compared to interobserver variation on a small subset of images. The DRL tracking result achieves a median overlapping rate until the first error (1.8 mm off the reference standard) of 100, [46, 100] % on 8032 vessels over 115 subjects. The bifurcation detector reaches an average recall and precision of 76% and 87% respectively during the vessel tree formation process. The final vessel tree formation achieves a median recall of 68% and precision of 70%, which is in line with the interobserver agreement.
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Affiliation(s)
- Jiahang Su
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
| | - Shuai Li
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Lennard Wolff
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Wim van Zwam
- Department of Radiology & Nuclear Medicine, Maastricht UMC, Cardiovascular Research Institute Maastricht, The Netherlands
| | - Wiro J Niessen
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Faculty of Applied Sciences, Delft University of Technology, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Theo van Walsum
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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8
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Ospel JM, Kunz WG, McDonough RV, van Zwam W, Pinckaers F, Saver JL, Hill MD, Demchuk AM, Jovin TG, Mitchell P, Campbell BCV, White P, Muir K, Achit H, Bracard S, Brown S, Goyal M. Cost-Effectiveness of Endovascular Treatment in Large Vessel Occlusion Stroke With Mild Prestroke Disability: Results From the HERMES Collaboration. Stroke 2023; 54:226-233. [PMID: 36472199 DOI: 10.1161/strokeaha.121.038407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical and economic benefit of endovascular treatment (EVT) in addition to best medical management in patients with stroke with mild preexisting symptoms/disability is not well studied. We aimed to investigate cost-effectiveness of EVT in patients with large vessel occlusion and mild prestroke symptoms/disability, defined as a modified Rankin Scale score of 1 or 2. METHODS Data are from the HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials), which pooled patient-level data from 7 large, randomized EVT trials. We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes from a health care and a societal perspective. Incremental cost-effectiveness ratio and net monetary benefits were calculated, and a probabilistic sensitivity analysis was performed. RESULTS EVT in addition to best medical management resulted in lifetime cost savings of $2821 (health care perspective) or $5378 (societal perspective) and an increment of 1.27 quality-adjusted life years compared with best medical management alone, indicating dominance of additional EVT as a treatment strategy. The net monetary benefits were higher for EVT in addition to best medical management compared with best medical management alone both at the higher (100 000$/quality-adjusted life years) and lower (50 000$/quality-adjusted life years) willingness to pay thresholds. Probabilistic sensitivity analysis showed decreased costs and an increase in quality-adjusted life years for additional EVT compared with best medical management only. CONCLUSIONS From a health-economic standpoint, EVT in addition to best medical management should be the preferred strategy in patients with acute ischemic stroke with large vessel occlusion and mild prestroke symptoms/disability.
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Affiliation(s)
- Johanna M Ospel
- Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.).,Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Germany (W.G.K.)
| | - Rosalie V McDonough
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Center, the Netherlands (W.v.Z.)
| | | | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Michael D Hill
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
| | - Tudor G Jovin
- Department of Neurology, Cooper University Health Care, Camden (T.G.J.)
| | - Peter Mitchell
- Department of Radiology (P.M.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Bruce C V Campbell
- Department of Neurology (B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Keith Muir
- Department of Neurology, University of Glasgow, Scotland (K.M.)
| | - Hamza Achit
- Department of Medicine (H.A.), Nancy University Hospital, France
| | - Serge Bracard
- Department of Neuroradiology (S.B.), Nancy University Hospital, France
| | - Scott Brown
- Altair Biostatistics, St Louis Park' MN (S.B.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada.,Department of Diagnostic Imaging (J.M.O., R.V.M., M.D.H., A.M.D., M.G.), University of Calgary, Canada
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9
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Su J, Wolff L, van Doormaal PJ, Dippel DWJ, van Zwam W, Niessen WJ, van der Lugt A, van Walsum T. Time dependency of automated collateral scores in computed tomography angiography and computed tomography perfusion images in patients with intracranial arterial occlusion. Neuroradiology 2023; 65:313-322. [PMID: 36167825 PMCID: PMC9859867 DOI: 10.1007/s00234-022-03050-4] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The assessment of collateral status may depend on the timing of image acquisition. The purpose of this study is to investigate whether there are optimal time points in CT Perfusion (CTP) for collateral status assessment, and compare collaterals scores at these time points with collateral scores from multiphase CT angiography (mCTA). METHODS Patients with an acute intracranial occlusion who underwent baseline non-contrast CT, mCTA and CT perfusion were selected. Collateral status was assessed using an automatically computed Collateral Ratio (CR) score in mCTA, and predefined time points in CTP acquisition. CRs extracted from CTP were correlated with CRs from mCTA. In addition, all CRs were related to baseline National Institutes of Health Stroke Scale (NIHSS) and Alberta Stoke Program Early CT Score (ASPECTS) with linear regression analysis to find the optimal CR. RESULTS In total 58 subjects (median age 74 years; interquartile range 61-83 years; 33 male) were included. When comparing the CRs from the CTP vs. mCTA acquisition, the strongest correlations were found between CR from baseline mCTA and the CR at the maximal intensity projection of time-resolved CTP (r = 0.81) and the CR at the peak of arterial enhancement point (r = 0.78). Baseline mCTA-derived CR had the highest correlation with ASPECTS (β = 0.36 (95%CI 0.11, 0.61)) and NIHSS (β = - 0.48 (95%CI - 0.72, - 0.16)). CONCLUSION Collateral status assessment strongly depends on the timing of acquisition. Collateral scores obtained from mCTA imaging is close to the optimal collateral score obtained from CTP imaging.
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Affiliation(s)
- Jiahang Su
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | - Lennard Wolff
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Wim van Zwam
- Department of Radiology, Maastricht UMC +, Maastricht, The Netherlands
| | - Wiro J Niessen
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
- Faculty of Applied Science, Delft University of Technology, Delft, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Theo van Walsum
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
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10
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Gerbasi A, Konduri P, Tolhuisen M, Cavalcante F, Rinkel L, Kappelhof M, Wolff L, Coutinho JM, Emmer BJ, Costalat V, Arquizan C, Hofmeijer J, Uyttenboogaart M, van Zwam W, Roos Y, Quaglini S, Bellazzi R, Majoie C, Marquering H. Prognostic Value of Combined Radiomic Features from Follow-Up DWI and T2-FLAIR in Acute Ischemic Stroke. J Cardiovasc Dev Dis 2022; 9:jcdd9120468. [PMID: 36547465 PMCID: PMC9786822 DOI: 10.3390/jcdd9120468] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
The biological pathways involved in lesion formation after an acute ischemic stroke (AIS) are poorly understood. Despite successful reperfusion treatment, up to two thirds of patients with large vessel occlusion remain functionally dependent. Imaging characteristics extracted from DWI and T2-FLAIR follow-up MR sequences could aid in providing a better understanding of the lesion constituents. We built a fully automated pipeline based on a tree ensemble machine learning model to predict poor long-term functional outcome in patients from the MR CLEAN-NO IV trial. Several feature sets were compared, considering only imaging, only clinical, or both types of features. Nested cross-validation with grid search and a feature selection procedure based on SHapley Additive exPlanations (SHAP) was used to train and validate the models. Considering features from both imaging modalities in combination with clinical characteristics led to the best prognostic model (AUC = 0.85, 95%CI [0.81, 0.89]). Moreover, SHAP values showed that imaging features from both sequences have a relevant impact on the final classification, with texture heterogeneity being the most predictive imaging biomarker. This study suggests the prognostic value of both DWI and T2-FLAIR follow-up sequences for AIS patients. If combined with clinical characteristics, they could lead to better understanding of lesion pathophysiology and improved long-term functional outcome prediction.
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Affiliation(s)
- Alessia Gerbasi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, 27100 PV Pavia, Italy
- Correspondence:
| | - Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Manon Tolhuisen
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, 3015 Rotterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Vincent Costalat
- Department of Neuroradiology, Centre Hospitalier Universitaire de Montpellier, 34400 Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Centre Hospitalier Universitaire de Montpellier, 34400 Montpellier, France
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, 6836 BH Arnhem, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology and Department of Medical Imaging Center, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, 27100 PV Pavia, Italy
| | - Riccardo Bellazzi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, 27100 PV Pavia, Italy
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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11
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Konduri P, Bucker A, Boers A, Dutra B, Samuels N, Treurniet K, Berkhemer O, Yoo A, van Zwam W, van Oostenbrugge R, van der Lugt A, Dippel D, Roos Y, Bot J, Majoie C, Marquering H. Risk factors of late lesion growth after acute ischemic stroke treatment. Front Neurol 2022; 13:977608. [PMID: 36277932 PMCID: PMC9581245 DOI: 10.3389/fneur.2022.977608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Even days after treatment of acute ischemic stroke due to a large vessel occlusion, the infarct lesion continues to grow. This late, subacute growth is associated with unfavorable functional outcome. In this study, we aim to identify patient characteristics that are risk factors of late, subacute lesion growth. Methods Patients from the MR CLEAN trial cohort with good quality 24 h and 1-week follow up non-contrast CT scans were included. Late Lesion growth was defined as the difference between the ischemic lesion volume assessed after 1-week and 24-h. To identify risk factors, patient characteristics associated with lesion growth (categorized in quartiles) in univariable ordinal analysis (p < 0.1) were included in a multivariable ordinal regression model. Results In the 226 patients that were included, the median lesion growth was 22 (IQR 10–45) ml. In the multivariable model, lower collateral capacity [aOR: 0.62 (95% CI: 0.44–0.87); p = 0.01], longer time to treatment [aOR: 1.04 (1–1.08); p = 0.04], unsuccessful recanalization [aOR: 0.57 (95% CI: 0.34–0.97); p = 0.04], and larger midline shift [aOR: 1.18 (95% CI: 1.02–1.36); p = 0.02] were associated with late lesion growth. Conclusion Late, subacute, lesion growth occurring between 1 day and 1 week after ischemic stroke treatment is influenced by lower collateral capacity, longer time to treatment, unsuccessful recanalization, and larger midline shift. Notably, these risk factors are similar to the risk factors of acute lesion growth, suggesting that understanding and minimizing the effects of the predictors for late lesion growth could be beneficial to mitigate the effects of ischemia.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- *Correspondence: Praneeta Konduri
| | - Amber Bucker
- Department of Radiology, University Medical Center Groningen, Groningen, Netherlands
| | - Anna Boers
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Nico-Lab, Amsterdam, Netherlands
| | - Bruna Dutra
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Noor Samuels
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Olvert Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Albert Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth, Dallas, TX, United States
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Joost Bot
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit van Amsterdam, Amsterdam, Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
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12
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van der Steen W, van der Sluijs PM, van de Graaf RA, Su R, Wolff L, van Voorst H, den Hertog HM, van Doormaal PJ, van Es ACGM, Staals J, van Zwam W, Lingsma HF, van den Berg R, Majoie CBLM, van der Lugt A, Dippel DWJ, Roozenbeek B. Safety and efficacy of periprocedural antithrombotics in patients with successful reperfusion after endovascular stroke treatment. J Stroke Cerebrovasc Dis 2022; 31:106726. [PMID: 36029687 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106726] [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: 07/08/2022] [Revised: 08/08/2022] [Accepted: 08/15/2022] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVES We aimed to evaluate whether the overall harmful effect of periprocedural treatment with aspirin or heparin during endovascular stroke treatment is different in patients with a successful reperfusion after the procedure. MATERIALS AND METHODS We performed a post-hoc analysis of the MR CLEAN-MED trial, including adult patients with a large vessel occlusion in the anterior circulation eligible for endovascular treatment (EVT). In this trial, patients were randomized for periprocedural intravenous treatment with aspirin or no aspirin (1:1 ratio), and for moderate-dose unfractionated heparin, low-dose unfractionated heparin or no unfractionated heparin (1:1:1 ratio). We tested for interaction between the post-EVT extended thrombolysis in cerebral infarction (eTICI) score and treatment with periprocedural medication with multivariable regression analyses. The primary outcome was the modified Rankin Scale score at 90 days. Secondary outcomes were final infarct volume, intracranial hemorrhage, and symptomatic intracranial hemorrhage. RESULTS Of 534 included patients, 93 (17%) had a post-EVT eTICI score of 0-2a, 115 (22%) a score of 2b, 73 (14%) a score of 2c, and 253 (47%) a score of 3. For both aspirin and heparin, we found no interaction between post-EVT eTICI score and treatment on the modified Rankin Scale score (p=0.76 and p=0.47, respectively). We found an interaction between post-EVT eTICI score and treatment with heparin on the final infarct volume (p=0.01). Of note, this interaction showed a biologically implausible distribution over the subgroups. CONCLUSIONS The overall harmful effect of periprocedural aspirin and unfractionated heparin is not different in patients with a successful reperfusion after EVT.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
| | - P Matthijs van der Sluijs
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ruisheng Su
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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13
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van der Steen W, van de Graaf RA, Chalos V, Lingsma HF, van Doormaal PJ, Coutinho JM, Emmer BJ, de Ridder I, van Zwam W, van der Worp HB, van der Schaaf I, Gons RAR, Yo LSF, Boiten J, van den Wijngaard I, Hofmeijer J, Martens J, Schonewille W, Vos JA, Tuladhar AM, de Laat KF, van Hasselt B, Remmers M, Vos D, Rozeman A, Elgersma O, Uyttenboogaart M, Bokkers RPH, van Tuijl J, Boukrab I, van den Berg R, Beenen LFM, Roosendaal SD, Postma AA, Krietemeijer M, Lycklama G, Meijer FJA, Hammer S, van der Hoorn A, Yoo AJ, Gerrits D, Truijman MTB, Zinkstok S, Koudstaal PJ, Manschot S, Kerkhoff H, Nieboer D, Berkhemer O, Wolff L, van der Sluijs PM, van Voorst H, Tolhuisen M, Roos YBWEM, Majoie CBLM, Staals J, van Oostenbrugge RJ, Jenniskens SFM, van Dijk LC, den Hertog HM, van Es ACGM, van der Lugt A, Dippel DWJ, Roozenbeek B. Safety and efficacy of aspirin, unfractionated heparin, both, or neither during endovascular stroke treatment (MR CLEAN-MED): an open-label, multicentre, randomised controlled trial. Lancet 2022; 399:1059-1069. [PMID: 35240044 DOI: 10.1016/s0140-6736(22)00014-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [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] [Received: 12/09/2021] [Revised: 12/27/2021] [Accepted: 01/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Aspirin and unfractionated heparin are often used during endovascular stroke treatment to improve reperfusion and outcomes. However, the effects and risks of anti-thrombotics for this indication are unknown. We therefore aimed to assess the safety and efficacy of intravenous aspirin, unfractionated heparin, both, or neither started during endovascular treatment in patients with ischaemic stroke. METHODS We did an open-label, multicentre, randomised controlled trial with a 2 × 3 factorial design in 15 centres in the Netherlands. We enrolled adult patients (ie, ≥18 years) with ischaemic stroke due to an intracranial large-vessel occlusion in the anterior circulation in whom endovascular treatment could be initiated within 6 h of symptom onset. Eligible patients had a score of 2 or more on the National Institutes of Health Stroke Scale, and a CT or MRI ruling out intracranial haemorrhage. Randomisation was done using a web-based procedure with permuted blocks and stratified by centre. Patients were randomly assigned (1:1) to receive either periprocedural intravenous aspirin (300 mg bolus) or no aspirin, and randomly assigned (1:1:1) to receive moderate-dose unfractionated heparin (5000 IU bolus followed by 1250 IU/h for 6 h), low-dose unfractionated heparin (5000 IU bolus followed by 500 IU/h for 6 h), or no unfractionated heparin. The primary outcome was the score on the modified Rankin Scale at 90 days. Symptomatic intracranial haemorrhage was the main safety outcome. Analyses were based on intention to treat, and treatment effects were expressed as odds ratios (ORs) or common ORs, with adjustment for baseline prognostic factors. This trial is registered with the International Standard Randomised Controlled Trial Number, ISRCTN76741621. FINDINGS Between Jan 22, 2018, and Jan 27, 2021, we randomly assigned 663 patients; of whom, 628 (95%) provided deferred consent or died before consent could be asked and were included in the modified intention-to-treat population. On Feb 4, 2021, after unblinding and analysis of the data, the trial steering committee permanently stopped patient recruitment and the trial was stopped for safety concerns. The risk of symptomatic intracranial haemorrhage was higher in patients allocated to receive aspirin than in those not receiving aspirin (43 [14%] of 310 vs 23 [7%] of 318; adjusted OR 1·95 [95% CI 1·13-3·35]) as well as in patients allocated to receive unfractionated heparin than in those not receiving unfractionated heparin (44 [13%] of 332 vs 22 [7%] of 296; 1·98 [1·14-3·46]). Both aspirin (adjusted common OR 0·91 [95% CI 0·69-1·21]) and unfractionated heparin (0·81 [0·61-1·08]) led to a non-significant shift towards worse modified Rankin Scale scores. INTERPRETATION Periprocedural intravenous aspirin and unfractionated heparin during endovascular stroke treatment are both associated with an increased risk of symptomatic intracranial haemorrhage without evidence for a beneficial effect on functional outcome. FUNDING The Collaboration for New Treatments of Acute Stroke consortium, the Brain Foundation Netherlands, the Ministry of Economic Affairs, Stryker, Medtronic, Cerenovus, and the Dutch Heart Foundation.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Bart J Emmer
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Inger de Ridder
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Irene van der Schaaf
- Department of Radiology, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rob A R Gons
- Department of Neurology, Catharina Hospital, Eindhoven, Netherlands
| | - Lonneke S F Yo
- Department of Radiology, Catharina Hospital, Eindhoven, Netherlands
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Ido van den Wijngaard
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands; Department of Radiology, Haaglanden Medical Centre, The Hague, Netherlands
| | | | - Jasper Martens
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, Netherlands
| | | | - Jan Albert Vos
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Anil Man Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Michel Remmers
- Department of Neurology, Amphia Hospital, Breda, Netherlands
| | - Douwe Vos
- Department of Radiology, Amphia Hospital, Breda, Netherlands
| | - Anouk Rozeman
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Otto Elgersma
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, Netherlands; Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Julia van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Issam Boukrab
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - René van den Berg
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Ludo F M Beenen
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Stefan D Roosendaal
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Alida Annechien Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | | | - Geert Lycklama
- Department of Radiology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Frederick J A Meijer
- Department of Medical Imaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Anouk van der Hoorn
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | | | - Martine T B Truijman
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | - Peter J Koudstaal
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sanne Manschot
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Olvert Berkhemer
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - P Matthijs van der Sluijs
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Henk van Voorst
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Manon Tolhuisen
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Sjoerd F M Jenniskens
- Department of Medical Imaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | | | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
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14
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Wolff L, Uniken Venema SM, Luijten SPR, Hofmeijer J, Martens JM, Bernsen MLE, van Es ACGM, van Doormaal PJ, Dippel DWJ, van Zwam W, van Walsum T, van der Lugt A. Diagnostic performance of an algorithm for automated collateral scoring on computed tomography angiography. Eur Radiol 2022; 32:5711-5718. [PMID: 35244761 PMCID: PMC9279191 DOI: 10.1007/s00330-022-08627-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/24/2021] [Accepted: 01/29/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Outcome of endovascular treatment in acute ischemic stroke patients depends on collateral circulation to provide blood supply to the ischemic territory. We evaluated the performance of a commercially available algorithm for assessing the collateral score (CS) in acute ischemic stroke patients. METHODS Retrospectively, baseline CTA scans (≤ 3-mm slice thickness) with an intracranial carotid artery (ICA), middle cerebral artery segment M1 or M2 occlusion, from the MR CLEAN Registry (n = 1627) were evaluated. All CTA scans were evaluated for visual CS (0-3) by eight expert radiologists (reference standard). A Web-based AI algorithm quantified the collateral circulation (0-100%) for correctly detected occlusion sides. Agreement between visual CS and categorized automated CS (0: 0%, 1: > 0- ≤ 50%, 2: > 50- < 100%, 3: 100%) was assessed. Area under the curve (AUC) values for classifying patients in having good (CS: 2-3) versus poor (CS: 0-1) collaterals and for predicting functional independence (90-day modified Rankin Scale 0-2) were computed. Influence of CTA acquisition timing after contrast material administration was reported. RESULTS In the analyzed scans (n = 1024), 59% agreement was found between visual CS and automated CS. An AUC of 0.87 (95% CI: 0.85-0.90) was found for discriminating good versus poor CS. Timing of CTA acquisition did not influence discriminatory performance. AUC for predicting functional independence was 0.66 (95% CI 0.62-0.69) for automated CS, similar to visual CS 0.64 (95% CI 0.61-0.68). CONCLUSIONS The automated CS performs similar to radiologists in determining a good versus poor collateral score and predicting functional independence in acute ischemic stroke patients with a large vessel occlusion. KEY POINTS • Software for automated quantification of intracerebral collateral circulation on computed tomography angiography performs similar to expert radiologists in determining a good versus poor collateral score. • Software for automated quantification of intracerebral collateral circulation on computed tomography angiography performs similar to expert radiologists in predicting functional independence in acute ischemic stroke patients with a large vessel occlusion. • The timing of computed tomography angiography acquisition after contrast material administration did not influence the performance of automated quantification of the collateral status.
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Affiliation(s)
- Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Simone M Uniken Venema
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sven P R Luijten
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Jasper M Martens
- Department of Radiology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Theo van Walsum
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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15
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Turc G, Tsivgoulis G, Audebert HJ, Boogaarts H, Bhogal P, De Marchis GM, Fonseca AC, Khatri P, Mazighi M, Pérez de la Ossa N, Schellinger PD, Strbian D, Toni D, White P, Whiteley W, Zini A, van Zwam W, Fiehler J. European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion. J Neurointerv Surg 2022; 14:209. [PMID: 35115395 DOI: 10.1136/neurintsurg-2021-018589] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [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: 12/20/2021] [Accepted: 01/09/2022] [Indexed: 12/30/2022]
Abstract
Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients with anterior circulation large vessel occlusion (LVO) ischemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach.For stroke patients with anterior circulation LVO directly admitted to a MT-capable center ('mothership') within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a center without MT facilities and eligible for IVT ≤4.5 hours and MT, we recommend IVT followed by rapid transfer to a MT capable-center ('drip-and-ship') in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU NeuroVasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Hieronymus Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, Barts NHS Trust, London, UK
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mikaël Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France.,Stroke Unit, Lariboisière Hospital AP-HP-Nord, FHU NeuroVasc, Université de Paris, Paris, France
| | | | - Peter D Schellinger
- Departments of Neurology and Neurogeriatrics, Johannes Wesling Medical Center Minden, University hospitals of the Ruhr-University of Bochum, Bochum, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Danilo Toni
- Hospital Policlinico Umberto I, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Turc G, Tsivgoulis G, Audebert H, Boogaarts H, Bhogal P, De Marchis GM, Fonseca AC, Khatri P, Mazighi M, Pérez de la Ossa N, Schellinger PD, Strbian D, Toni D, White P, Whiteley W, Zini A, van Zwam W, Fiehler J. EXPRESS: European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion. Eur Stroke J 2022; 7:I-XXVI. [PMID: 35300256 PMCID: PMC8921785 DOI: 10.1177/23969873221076968] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022] Open
Abstract
Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients with anterior circulation large vessel occlusion (LVO) ischaemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach.
For stroke patients with anterior circulation LVO directly admitted to a MT-capable centre (“mothership”) within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a centre without MT facilities and eligible for IVT ≤4.5 hrs and MT, we recommend IVT followed by rapid transfer to a MT capable-centre (“drip-and-ship”) in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischaemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
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Affiliation(s)
| | - Georgios Tsivgoulis
- Department of Neuology, University Hospital of AlexandroupolisDemocritus University of Thrace
| | | | | | | | | | | | - Pooja Khatri
- NeurologyUniversity of Cincinnati Medical Center
| | | | | | | | | | - Danilo Toni
- Human NeurosciencesSapienza University of Rome
| | - Phil White
- Institute of Neuroscience (Stroke Research Group)Newcastle University
| | | | | | - Wim van Zwam
- NeurologyMaastricht University Faculty of Health Medicine and Life Sciences
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17
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Bruggeman AA, Boodt N, Kappelhof M, Hoving AJ, Brouwer J, Tolhuisen M, Arrarte Terreros N, Konduri P, van Kranendonk KR, Dippel DW, van der Lugt A, van Zwam W, van der Leij C, van Es AC, Cornelissen S, Brans R, Marquering H, Majoie CB, Emmer B. Abstract TP152: A Comparison Of Thrombus Characteristics In Patients With Anterior Circulation Stroke And Posterior Circulation Stroke In The Mr Clean Registry. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tp152] [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:
In posterior circulation stroke (PCS), large artery atherosclerosis at the occlusion site or dissection is most often reported as underlying stroke etiology, while cardio embolism is less common than in anterior circulation stroke (ACS). As thrombus characteristics are related to the underlying stroke etiology, we hypothesized that differences in radiological thrombus characteristics between PCS and ACS are fully explained by differences in underlying etiology. We compared radiological thrombus characteristics between PCS and ACS to gain insight in the differences in order to optimize treatment options for PCS.
Methods:
In patients treated with endovascular treatment (EVT) for acute ischemic stroke in the MR CLEAN Registry, radiological thrombus characteristics (perviousness, density, and length) were assessed on thin-slice (<2.5mm) non-contrast computed tomography and computed tomography angiography imaging acquired within 30 minutes from each other. Radiological thrombus characteristics between PCS and ACS patients were compared with univariable and multivariable linear regression with adjustments for baseline differences which could influence thrombus characteristics (age, gender, TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria and intravenous alteplase treatment.
Results:
We analyzed 1052 patients: 118 PCS and 934 ACS patients. PCS thrombi were significantly longer and denser than ACS thrombi: median 23 mm vs 18 mm (p<0.001) and median 53 HU vs 50 HU respectively (p=0.04) (Table 1). After adjustments, thrombus length was significantly different: PCS thrombi were 15 mm longer compared with ACS thrombi (aβ 15, 95% CI 12-18), while thrombus density and perviousness did not significantly differ between ACS and PCS (Table 1).
Conclusion:
PCS thrombi are significantly longer and denser than ACS thrombi. After adjustment for stroke etiology, only thrombus length was significantly different between PCS and ACS patients.
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Affiliation(s)
| | - Nikki Boodt
- Erasmus Univ Med Cntr, Rotterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rutger Brans
- Maastricht Univ Med Cntr, Maastricht, Netherlands
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van der Ende NAM, Roozenbeek B, Berkhemer OA, Koudstaal PJ, Boiten J, van Dijk EJ, Roos YBWEM, van Oostenbrugge RJ, Majoie CBLM, van Zwam W, Lingsma HF, van der Lugt A, Dippel DWJ. Added Value of a Blinded Outcome Adjudication Committee in an Open-Label Randomized Stroke Trial. Stroke 2021; 53:61-69. [PMID: 34607469 PMCID: PMC8700318 DOI: 10.1161/strokeaha.121.035301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Supplemental Digital Content is available in the text. Blinded outcome assessment in trials with prospective randomized open blinded end point design is challenging. Unblinding can result in misclassified outcomes and biased treatment effect estimates. An outcome adjudication committee assures blinded outcome assessment, but the added value for trials with prospective randomized open blinded end point design and subjective outcomes is unknown. We aimed to assess the degree of misclassification of modified Rankin Scale (mRS) scores by a central assessor and its impact on treatment effect estimates in a stroke trial with prospective randomized open blinded end point design.
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Affiliation(s)
- Nadinda A M van der Ende
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., P.J.K., D.W.J.D.).,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., A.v.d.L.)
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., P.J.K., D.W.J.D.).,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., A.v.d.L.)
| | - Olvert A Berkhemer
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., P.J.K., D.W.J.D.).,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., A.v.d.L.).,Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands. (O.A.B., C.B.L.M.M.).,Department of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands. (O.A.B., Y.B.W.E.M.R.)
| | - Peter J Koudstaal
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., P.J.K., D.W.J.D.)
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands (J.B.)
| | - Ewoud J van Dijk
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands (E.J.v.D.)
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands. (O.A.B., Y.B.W.E.M.R.)
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (R.J.v.O.)
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands. (O.A.B., C.B.L.M.M.)
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (W.v.Z.)
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (H.F.L.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., A.v.d.L.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands. (N.A.M.v.d.E., B.R., O.A.B., P.J.K., D.W.J.D.)
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De Beule T, Boulanger T, Heye S, van Rooij WJ, van Zwam W, Stockx L. The Woven EndoBridge for unruptured intracranial aneurysms: Results in 95 aneurysms from a single center. Interv Neuroradiol 2021; 27:594-601. [PMID: 33745363 PMCID: PMC8493345 DOI: 10.1177/15910199211003428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE The Woven EndoBridge (WEB) is an intrasaccular flowdisruptor that is increasingly used for the treatment of (wide-necked) aneurysms. We present our experience with the WEB for unruptured aneurysms. MATERIALS AND METHODS Between April 2014 and August 2019, 93 patients with 95 unruptured aneurysms were primarily treated with the WEB. There were 69 women and 24 men, mean age 61 years (median 58, range 37-80). RESULTS Of 95 aneurysms, 86 had been discovered incidentally, 3 were symptomatic and 6 were additional to another ruptured aneurysm. Location was anterior communicating artery 33, middle cerebral artery 29, basilar tip 19, carotid tip 8, posterior communicating artery 4, posterior inferior cerebellar artery 1, superior cerebellar artery 1. Mean aneurysm size was 6 mm (median 6, range 3-13 mm).In one aneurysm additional coils were used and in another, a stent was placed. There was one procedural rupture without clinical sequelae. There were two thrombo-embolic complications leading to permanent deficit in one patient (mRS 2). Morbidity rate was 1.0% (1 of 93, 95%CI 0.01-6.5%) and mortality was 0% (0 of 93, 95%CI 0.0-4.8%). Angiographic follow-up at six months was available in 85 patients with 87 aneurysms (91%). Of 87 aneurysms, 68 (78%) were completely occluded, 14 (16%) had a neck remnant and 5 were incompletely occluded. Four aneurysms were retreated. Retreatment rate was 4.5% (4 of 87, 95%CI 1.7-13.6%). CONCLUSION WEB treatment of unruptured aneurysms is safe and effective. Additional devices are needed only rarely and retreatment at follow-up is infrequent.
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Affiliation(s)
- Tom De Beule
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Sam Heye
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Wim van Zwam
- Department of Radiology, Maastricht Universiteit Medisch Centrum, Maastricht, the Netherlands
| | - Luc Stockx
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
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20
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Tolhuisen ML, Ernst M, Boers AMM, Brown S, Beenen LFM, Guillemin F, Roos YBWEM, Saver JL, van Oostenbrugge R, Demchuck AM, van Zwam W, Jovin TG, Berkhemer OA, Muir KW, Bracard S, Campbell BCV, van der Lugt A, White P, Hill MD, Dippel DWJ, Mitchell PJ, Goyal M, Caan MWA, Marquering HA, Majoie CBLM. Value of infarct location in the prediction of functional outcome in patients with an anterior large vessel occlusion: results from the HERMES study. Neuroradiology 2021; 64:521-530. [PMID: 34476512 PMCID: PMC8850210 DOI: 10.1007/s00234-021-02784-x] [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: 06/09/2021] [Accepted: 08/01/2021] [Indexed: 11/22/2022]
Abstract
Purpose Follow-up infarct volume (FIV) is moderately associated with functional outcome. We hypothesized that accounting for infarct location would strengthen the association of FIV with functional outcome. Methods We included 252 patients from the HERMES collaboration with follow-up diffusion weighted imaging. Patients received endovascular treatment combined with best medical management (n = 52%) versus best medical management alone (n = 48%). FIV was quantified in low, moderate and high modified Rankin Scale (mRS)-relevant regions. We used binary logistic regression to study the relation between the total, high, moderate or low mRS-relevant FIVs and favorable outcome (mRS < 2) after 90 days. The strength of association was evaluated using the c-statistic. Results Small lesions only occupied high mRS-relevant brain regions. Lesions additionally occupied lower mRS-relevant brain regions if FIV expanded. Higher FIV was associated with a higher risk of unfavorable outcome, as were volumes of tissue with low, moderate and high mRS relevance. In multivariable modeling, only the volume of high mRS-relevant infarct was significantly associated with favorable outcome. The c-statistic was highest (0.76) for the models that included high mRS-relevant FIV or the combination of high, moderate and low mRS-relevant FIV but was not significantly different from the model that included only total FIV (0.75). Conclusion This study confirms the association of FIV and unfavorable functional outcome but showed no strengthened association if lesion location was taken into account.
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Affiliation(s)
- Manon L Tolhuisen
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands. .,Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Scott Brown
- Altair Biostatistics, St Louis Park, MN, USA
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Francis Guillemin
- CIC-Epidémiologie Clinique, 1433, Inserm, CHRU, Université de Lorraine, Nancy, France
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Robert van Oostenbrugge
- Department of Neurology, Maastricht UMC, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Andrew M Demchuck
- Department of Clinical Neurosciences, Department of Radiology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Wim van Zwam
- Department of Radiology, Maastricht UMC, Maastricht, The Netherlands
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.,Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, University Avenue, Glasgow, UK
| | - Serge Bracard
- CIC-Epidémiologie Clinique, 1433, Inserm, CHRU, Université de Lorraine, Nancy, France.,Department of Diagnostic and Interventional Neuroradiology, IADI, Inserm, CHRU, Université de Lorraine, Nancy, France
| | - Bruce C V Campbell
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Aad van der Lugt
- Institute of Neuroscience and Psychology, University of Glasgow, University Avenue, Glasgow, UK
| | - Phill White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Department of Neuroradiology, Newcastle upon Tyne hospitals, Newcastle upon Tyne, UK
| | - Michael D Hill
- Department of Clinical Neurosciences, Department of Radiology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary & Foothills Medical Centre, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary & Foothills Medical Centre, Calgary, Calgary, Canada
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter J Mitchell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mayank Goyal
- Department of Clinical Neurosciences, Department of Radiology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthan W A Caan
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
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21
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Konduri P, van Voorst H, Bucker A, van Kranendonk K, Boers A, Treurniet K, Berkhemer O, Yoo AJ, van Zwam W, van Oostenbrugge R, van der Lugt A, Dippel D, Roos Y, Bot J, Majoie C, Marquering H. Posttreatment Ischemic Lesion Evolution Is Associated With Reduced Favorable Functional Outcome in Patients With Stroke. Stroke 2021; 52:3523-3531. [PMID: 34289708 DOI: 10.1161/strokeaha.120.032331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic lesion volume can increase even 24 hours after onset of an acute ischemic stroke. In this study, we investigated the association of lesion evolution with functional outcome and the influence of successful recanalization on this association. METHODS We included patients from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) who received good quality noncontrast CT images 24 hours and 1 week after stroke onset. The ischemic lesion delineations included infarct, edema, and hemorrhagic transformation. Lesion evolution was defined as the difference between the volumes measured on the 1-week and 24-hour noncontrast CTs. The association of lesion evolution with functional outcome was evaluated using unadjusted and adjusted logistic regression. Adjustments were made for baseline, clinical, and imaging parameters that were associated P<0.10) in univariate analysis with favorable functional outcome, defined as modified Rankin Scale score of ≤2. Interaction analysis was performed to evaluate the influence of successful recanalization, defined as modified Arterial Occlusion Lesion score of 3 points, on this association. RESULTS Of the 226 patients who were included, 69 (31%) patients achieved the favorable functional outcome. Median lesion evolution was 22 (interquartile range, 10-45) mL. Lesion evolution was significantly inversely correlated with favourable functional outcome: unadjusted odds ratio, 0.76 (95% CI, 0.66-0.86; per 10 mL of lesion evolution; P<0.01) and adjusted odds ratio: 0.85 (95% CI, 0.72-0.97; per 10 mL of lesion evolution; P=0.03). There was no significant interaction of successful recanalization on the association of lesion evolution and favorable functional outcome (odds ratio, 1.01 [95% CI, 0.77-1.36]; P=0.94). CONCLUSIONS In our population, subacute ischemic lesion evolution is associated with unfavorable functional outcome. This study suggests that even 24 hours after onset of stroke, deterioration of the brain continues, which has a negative effect on functional outcome. This finding may warrant additional treatment in the subacute phase.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics (P.K., H.v.V., A.B., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Henk van Voorst
- Department of Biomedical Engineering and Physics (P.K., H.v.V., A.B., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Amber Bucker
- Department of Biomedical Engineering and Physics (P.K., H.v.V., A.B., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Katinka van Kranendonk
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Anna Boers
- Department of Radiology, University Medical Center Groningen, the Netherlands (A.B.)
- Nico-lab, Amsterdam, Netherlands (A.B.)
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Radiology, Haaglanden Medisch Centrum, The Hague, the Netherlands (K.T.)
| | - Olvert Berkhemer
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Neurology (O.B., D.D.), Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Radiology & Nuclear Medicine (O.B., A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.)
| | - Wim van Zwam
- Department of Radiology (W.v.Z.), Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)
| | - Robert van Oostenbrugge
- Department of Neurology (R.v.O.), Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine (O.B., A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Diederik Dippel
- Department of Neurology (O.B., D.D.), Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology (Y.R.), Amsterdam UMC, location AMC, the Netherlands
| | - Joost Bot
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit van Amsterdam (J.B.)
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics (P.K., H.v.V., A.B., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
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22
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Konduri P, van Kranendonk K, Boers A, Treurniet K, Berkhemer O, Yoo AJ, van Zwam W, van Oostenbrugge R, van der Lugt A, Dippel D, Roos Y, Bot J, Majoie C, Marquering H. The Role of Edema in Subacute Lesion Progression After Treatment of Acute Ischemic Stroke. Front Neurol 2021; 12:705221. [PMID: 34354669 PMCID: PMC8329530 DOI: 10.3389/fneur.2021.705221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Ischemic lesions commonly continue to progress even days after treatment, and this lesion growth is associated with unfavorable functional outcome in acute ischemic stroke patients. The aim of this study is to elucidate the role of edema in subacute lesion progression and its influence on unfavorable functional outcome by quantifying net water uptake. Methods: We included all 187 patients from the MR CLEAN trial who had high quality follow-up non-contrast CT at 24 h and 1 week. Using a CT densitometry-based method to calculate the net water uptake, we differentiated total ischemic lesion volume (TILV) into edema volume (EV) and edema-corrected infarct volume (ecIV). We calculated these volumes at 24 h and 1 week after stroke and determined their progression in the subacute period. We assessed the effect of 24-h lesion characteristics on EV and ecIV progression. We evaluated the influence of edema and edema-corrected infarct progression on favorable functional outcome after 90 days (modified Rankin Scale: 0-2) after correcting for potential confounders. Lastly, we compared these volumes between subgroups of patients with and without successful recanalization using the Mann-Whitney U-test. Results: Median TILV increased from 37 (IQR: 18-81) ml to 68 (IQR: 30-130) ml between 24 h and 1 week after stroke, while the net water uptake increased from 22 (IQR: 16-26)% to 27 (IQR: 22-32)%. The TILV progression of 20 (8.8-40) ml was mostly caused by ecIV with a median increase of 12 (2.4-21) ml vs. 6.5 (2.7-15) ml of EV progression. Larger TILV, EV, and ecIV volumes at 24 h were all associated with more edema and lesion progression. Edema progression was associated with unfavorable functional outcome [aOR: 0.53 (0.28-0.94) per 10 ml; p-value: 0.05], while edema-corrected infarct progression showed a similar, non-significant association [aOR: 0.80 (0.62-0.99); p-value: 0.06]. Lastly, edema progression was larger in patients without successful recanalization, whereas ecIV progression was comparable between the subgroups. Conclusion: EV increases in evolving ischemic lesions in the period between 1 day and 1 week after acute ischemic stroke. This progression is larger in patients without successful recanalization and is associated with unfavorable functional outcome. However, the extent of edema cannot explain the total expansion of ischemic lesions since edema-corrected infarct progression is larger than the edema progression.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Katinka van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Anna Boers
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Nico.lab, Amsterdam, Netherlands
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Olvert Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Neurology, Erasmus MC-University Medical Center, Rotterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth, TX, United States
| | - Wim van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Joost Bot
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit van Amsterdam, Amsterdam, Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
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23
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Ospel JM, Brown S, Kappelhof M, van Zwam W, Jovin T, Roy D, Campbell BCV, Mitchell P, Roos Y, Guillemin F, Buck B, Muir K, Bracard S, White P, du Mesnil de Rochemont R, Goyal M. Comparing the Prognostic Impact of Age and Baseline National Institutes of Health Stroke Scale in Acute Stroke due to Large Vessel Occlusion. Stroke 2021; 52:2839-2845. [PMID: 34233465 DOI: 10.1161/strokeaha.120.032364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Johanna Maria Ospel
- Department of Clinical Neurosciences (J.M.O., M.G.), University of Calgary, Alberta, Canada.,Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.)
| | - Scott Brown
- Altair Biostatistics, St Louis Park, MN (S.B.)
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands (M.K.)
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, School for Mental Health and Sciences, Maastricht University Medical Center, the Netherlands (W.v.Z.)
| | - Tudor Jovin
- Department of Neurology, University of Pittsburgh, PA (T.J.)
| | - Daniel Roy
- Centre Hospitalier de l'Université de Montréal, Canada (D.R.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (B.C.V.C.)
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia (P.M.)
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands (Y.R.)
| | - Francis Guillemin
- Department of Clinical Epidemiology, Université de Lorraine, University Hospital of Nancy, France (F.G.)
| | - Brian Buck
- University of Alberta Hospital, Edmonton, Canada (B.B.)
| | - Keith Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Scotland (K.M.)
| | - Serge Bracard
- Department of Radiology, Université de Lorraine, Nancy, France (S.B.)
| | - Phil White
- Department of Radiology, Newcastle University, Newcastle Upon Tyne, United Kingdom (P.W.)
| | | | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., M.G.), University of Calgary, Alberta, Canada.,Department of Radiology (M.G.), University of Calgary, Alberta, Canada
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Nardai S, Lanzer P, Abelson M, Baumbach A, Doehner W, Hopkins LN, Kovac J, Meuwissen M, Roffi M, Sievert H, Skrypnik D, Sulzenko J, van Zwam W, Gruber A, Ribo M, Cognard C, Szikora I, Flodmark O, Widimsky P. Interdisciplinary management of acute ischaemic stroke: Current evidence training requirements for endovascular stroke treatment. Position Paper from the ESC Council on Stroke and the European Association for Percutaneous Cardiovascular Interventions with the support of the European Board of Neurointervention. Eur Heart J 2021; 42:298-307. [PMID: 33521827 DOI: 10.1093/eurheartj/ehaa833] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/07/2020] [Accepted: 09/23/2020] [Indexed: 11/15/2022] Open
Abstract
This ESC Council on Stroke/EAPCI/EBNI position paper summarizes recommendations for training of cardiologists in endovascular treatment of acute ischaemic stroke. Interventional cardiologists adequately trained to perform endovascular stroke interventions could complement stroke teams to provide the 24/7 on call duty and thus to increase timely access of stroke patients to endovascular treatment. The training requirements for interventional cardiologists to perform endovascular therapy are described in details and should be based on two main principles: (i) patient safety cannot be compromised, (ii) proper training of interventional cardiologists should be under supervision of and guaranteed by a qualified neurointerventionist and within the setting of a stroke team. Interdisciplinary cooperation based on common standards and professional consensus is the key to the quality improvement in stroke treatment.
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Affiliation(s)
- Sandor Nardai
- Department Section of Neurointervention, National Institute of Clinical Neurosciences, Semmelweis University Heart and Vascular Center and Semmelweis University, Budapest, Hungary
| | - Peter Lanzer
- Mitteldeutsches Herzzentrum, Standort Bitterfeld-Wolfen, Germany
| | - Mark Abelson
- Vergelegen MediClinic, Somerset West, University of Cape Town, South Africa
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), and Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany
| | - L Nelson Hopkins
- Gates Vascular Institute and Jacobs Institute, Neurosurgery and Radiology, University at Buffalo, USA
| | - Jan Kovac
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Marco Roffi
- Division of cardiology, University Hospitals, Geneva, Switzerland
| | - Horst Sievert
- CardioVascular Center Frankfurt, Germany and Anglia Ruskin University, Chelmsford, UK
| | - Dmitry Skrypnik
- Department of Interventional Cardiology, Moscow Hospital I. Davydovsky and Moscow State University of Medicine and Dentistry, Russian Federation
| | - Jakub Sulzenko
- Cardiocenter, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicin, Academic Hospital of Maastricht, Maastricht, The Netherlands
| | - Andreas Gruber
- Universitätsklinik für Neurochirurgie, Kepler Universitäts Klinikum, Linz, Austria
| | - Marc Ribo
- Department of Neurology, Hospital Wall d'Hebron, Barcelona, Spain
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology Hôpital Purpan, Toulouse, France
| | - Istvan Szikora
- Department Section of Neurointervention, National Institute of Clinical Neurosciences, Semmelweis University, Budapest, Hungary
| | - Olof Flodmark
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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25
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Wouters A, Robben D, Christensen S, Marquering H, Roos Y, Oostenbrugge RVV, van Zwam W, DIPPEL DW, Majoie CB, van der Lugt A, Lansberg MG, Albers GW, Suetens P, Lemmens R. Abstract P333: Prediction of Stroke Lesion Growth Rates by Baseline Perfusion Imaging. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Computed Tomography Perfusion imaging (CTP) allows estimation of tissue status in patients with acute ischemic stroke. We aimed to improve prediction of the final infarct and individual infarct growth rates based on a deep learning approach.
Methods:
We trained a deep neural network to predict the final infarct volume in patients presenting with large vessel occlusions based on the native CTP images, time to reperfusion and reperfusion status in a derivation cohort (MR CLEAN study). The model was internally validated in a five-fold cross-validation and externally in an independent dataset (CRISP study). We calculated the mean absolute difference (MAD) between the predictions of the deep learning model and the final infarct volume versus the MAD between CTP processing by RAPID software and the final infarct volume. Next, we determined infarct growth rates for every patient.
Results:
We included 127 patients from the MR CLEAN (derivation) and 101 patients of the CRISP study (validation). The deep learning model improved final infarct lesion prediction compared to the RAPID software in both the derivation, MAD 34.5 vs 52.4ml, and validation cohort, 41.2 vs 52.4 ml, (p < 0.01). We obtained individual infarct growth rates enabling the estimation of final infarct volume based on time and grade of reperfusion.
Interpretation:
We validated a deep learning-based method which improved final infarct volume estimations compared to classic CTP processing. In addition, the deep learning model predicted individual infarct growth rates which could potentially enable the introduction of tissue clocks during the management of acute stroke.
Figure
A.
Patient with a mean infarct growth of 18.3 ml/h. The final infarct volume was 104 ml. Recanalization was performed 131 min after CT perfusion with a mTICI = 2b.
B
. Patient with a mean infarct growth of 2.3 ml/h. The final infarct volume was 10.8 ml. Recanalization was performed 101 min after CT perfusion with a mTICI = 3.
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26
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. .,Department of Radiology, University of Calgary, Calgary, Canada.
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, School for Mental Health and Sciences, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jacques Moret
- The Brain Vascular Center, Baujon University Hospital, Paris, France
| | - Johanna Maria Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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27
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Ospel J, Kashani N, Mayank A, Kaesmacher J, Hanning U, Brinjikji W, Cloft H, Almekhlafi M, Mitha AP, Wong JH, Costalat V, van Zwam W, Goyal M. Physician factors influencing endovascular treatment decisions in the management of unruptured intracranial aneurysms. Neuroradiology 2020; 63:117-123. [PMID: 32740709 DOI: 10.1007/s00234-020-02509-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/28/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Deciding about whether an unruptured intracranial aneurysm (UIA) should be treated or not is challenging because robust data on rupture risks, endovascular treatment complication rates, and treatment success rates are limited. We aimed to investigate how neurointerventionalists conceptually approach endovascular treatment decision-making in UIAs. METHODS In a web-based international multidisciplinary case-based survey among neurointerventionalists, participants provided their demographics and UIA treatment-volumes, estimated 5-year rupture rates, endovascular treatment complication and success rates and gave their endovascular treatment decision for 15 pre-specified UIA case-scenarios. Differences in estimated 5-year rupture rates, endovascular treatment complication and success rates based on physician and hospital characteristics were evaluated with the Kruskal-Wallis test. Multivariable logistic regression analysis was used to derive adjusted effect size estimates for predictors of endovascular treatment decision. RESULTS Two hundred-thirty-three neurointerventionalists from 38 countries participated in the survey (median age 47 years [IQR: 41-55], 25/233 [10.7%] females). The ranges of estimates for 5-year rupture risks, endovascular treatment complication rates, and particularly endovascular treatment success rates were wide, especially for UIAs in the posterior circulation. Estimated 5-year rupture risks, endovascular treatment complication and success rates differed significantly based on personal and institutional endovascular UIA treatment volume, and all three estimates were significantly associated with physicians' endovascular treatment decision. CONCLUSION Although several predictors of endovascular treatment decision were identified, there seems to be a high degree of uncertainty when estimating rupture risks, treatment complications, and treatment success for endovascular UIA treatment. More data on the clinical course of UIAs with and without endovascular treatment is needed.
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Affiliation(s)
- Johanna Ospel
- Department of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nima Kashani
- Department of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.,Department of Radiology, University of Calgary, Calgary, Canada
| | - Arnuv Mayank
- Department of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Harry Cloft
- Department of Radiology, Mayo Clinic, Rochester, NY, USA
| | - Mohammed Almekhlafi
- Department of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.,Department of Radiology, University of Calgary, Calgary, Canada
| | - Alim P Mitha
- Department of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.,Department of Radiology, University of Calgary, Calgary, Canada.,Division of Neurosurgery, University of Calgary, Calgary, Canada
| | - John H Wong
- Department of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada.,Department of Radiology, University of Calgary, Calgary, Canada.,Division of Neurosurgery, University of Calgary, Calgary, Canada
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, School for Mental Health and Sciences, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Mayank Goyal
- Department of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada. .,Department of Radiology, University of Calgary, Calgary, Canada.
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28
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Su J, Wolff L, van Es ACGM, van Zwam W, Majoie C, W J Dippel D, van der Lugt A, J Niessen W, Van Walsum T. Automatic Collateral Scoring From 3D CTA Images. IEEE Trans Med Imaging 2020; 39:2190-2200. [PMID: 31944937 DOI: 10.1109/tmi.2020.2966921] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The collateral score is an important biomarker in decision making for endovascular treatment (EVT) of patients with ischemic stroke. The existing collateral grading systems are based on visual inspection and prone to subjective interpretation and interobserver variation. The purpose of our work is the development of an automatic collateral scoring method. In this work, we present a method that is inspired by human collateral scoring. Firstly, we define an anatomical region by atlas-based registration and extract vessel structures using a deep convolutional neural network. From this, high-level features based on the ratios of vessel length and volume of the occluded and the contralateral side are defined. Multi-class classification models are used to map the feature space to a four-grade collateral score and a quantitative score. The dataset used for training, validation and testing is from a registry of images acquired in clinical routine at multiple medical centers. The model performance is tested on 269 subjects, achieving an accuracy of 0.8. The dichotomized collateral score accuracy is 0.9. The error is comparable to the interobserver variation, the results are comparable to the performance of two radiologists with 10 to 30 years of experience.
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29
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van Kranendonk KR, Kappelhof M, Chalos V, Treurniet KM, van Zwam W, van Oostenbrugge RJ, Lingsma HF, Dippel DW, van der Lugt A, Mitchell PJ, Hill MD, Jovin TG, Davalos A, Campbell BC, Saver JL, White P, Bracard S, Guillemin F, Demchuk A, Brown S, Muir K, Roos YB, Marquering HA, Goyal M, Majoie CB. Abstract 75: Hemorrhagic Transformation After Acute Ischemic Stroke Due to a Large Vessel Occlusion is Associated With Less Treatment Benefit. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.75] [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:
Intracranial hemorrhage after acute ischemic stroke patients manifests as natural progression or as a complication of treatment with potential subsequent neurological deterioration. Currently it is unclear whether these hemorrhagic transformations (HT) contribute to the poorer functional outcomes observed in patients with large infarcts. The purpose of this study is to assess the association of HT with follow-up infarct volume (FIV) and functional outcome at 90 days after AIS. Additionally, we determined whether the development of HT was associated with a diminished endovascular therapy (EVT) effect.
Methods:
All patients from the HERMES collaboration with follow-up imaging were included. HERMES is pooled data from seven randomized controlled trials that assessed the efficacy and safety of EVT compared to usual care. Patients with HT were identified according to the ECASS classification and FIV was assessed on CT or MRI. Infarct and hemorrhage were included in the FIV. We assessed functional outcome using the modified Rankin Scale 90 days after stroke onset. Ordinal logistic regression with adjustment for potential confounders was used to determine the association of HT and FIV with functional outcome.
Results:
Of all included patients with follow-up imaging (n=1665), 42% had HT (n=698). Before and after adjustment for confounders HT and FIV were associated with a shift in the direction of poorer functional outcome (aOR:0.71,95%CI:0.58-0.86 and aOR:0.99,95%CI:0.99-0.99). EVT was beneficial in patients with and without HT, but effect was greater in patients without (aOR:1.70,95%CI:1.27-2.28 vs. aOR:2.51,95%CI:1.97-3.20)(figure 1.)
Conclusions:
In this analysis, patients with HT after AIS were less likely to have good functional outcome compared to those without HT, independent of the FIV. While the EVT effect was slightly diminished in patients who developed HT, EVT was always of significant benefit.
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Affiliation(s)
| | | | | | | | - Wim van Zwam
- Maastricht Univ Med Cntr, Maastricht, Netherlands
| | | | | | | | | | | | | | | | | | | | | | - Phil White
- Newcastle Univ, Newcastle, United Kingdom
| | | | | | | | | | - Keith Muir
- Univ of Glasgow, Glasgow, United Kingdom
| | - Yvo B Roos
- Amsterdam UMC, location AMC, Amsterdam, Netherlands
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30
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Chamorro Á, Brown S, Amaro S, Hill MD, Muir KW, Dippel DWJ, van Zwam W, Butcher K, Ford GA, den Hertog HM, Mitchell PJ, Demchuk AM, Majoie CBLM, Bracard S, Sibon I, Jadhav AP, Lara-Rodriguez B, van der Lugt A, Osei E, Renú A, Richard S, Rodriguez-Luna D, Donnan GA, Dixit A, Almekhlafi M, Deltour S, Epstein J, Guillon B, Bakchine S, Gomis M, du Mesnil de Rochemont R, Lopes D, Reddy V, Rudel G, Roos YBWEM, Bonafe A, Diener HC, Berkhemer OA, Cloud GC, Davis SM, van Oostenbrugge R, Guillemin F, Goyal M, Campbell BCV, Menon BK. Glucose Modifies the Effect of Endovascular Thrombectomy in Patients With Acute Stroke. Stroke 2019; 50:690-696. [PMID: 30777000 DOI: 10.1161/strokeaha.118.023769] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Hyperglycemia is a negative prognostic factor after acute ischemic stroke but is not known whether glucose is associated with the effects of endovascular thrombectomy (EVT) in patients with large-vessel stroke. In a pooled-data meta-analysis, we analyzed whether serum glucose is a treatment modifier of the efficacy of EVT in acute stroke. Methods- Seven randomized trials compared EVT with standard care between 2010 and 2017 (HERMES Collaboration [highly effective reperfusion using multiple endovascular devices]). One thousand seven hundred and sixty-four patients with large-vessel stroke were allocated to EVT (n=871) or standard care (n=893). Measurements included blood glucose on admission and functional outcome (modified Rankin Scale range, 0-6; lower scores indicating less disability) at 3 months. The primary analysis evaluated whether glucose modified the effect of EVT over standard care on functional outcome, using ordinal logistic regression to test the interaction between treatment and glucose level. Results- Median (interquartile range) serum glucose on admission was 120 (104-140) mg/dL (6.6 mmol/L [5.7-7.7] mmol/L). EVT was better than standard care in the overall pooled-data analysis adjusted common odds ratio (acOR), 2.00 (95% CI, 1.69-2.38); however, lower glucose levels were associated with greater effects of EVT over standard care. The interaction was nonlinear such that significant interactions were found in subgroups of patients split at glucose < or >90 mg/dL (5.0 mmol/L; P=0.019 for interaction; acOR, 3.81; 95% CI, 1.73-8.41 for patients < 90 mg/dL versus 1.83; 95% CI, 1.53-2.19 for patients >90 mg/dL), and glucose < or >100 mg/dL (5.5 mmol/L; P=0.004 for interaction; acOR, 3.17; 95% CI, 2.04-4.93 versus acOR, 1.72; 95% CI, 1.42-2.08) but not between subgroups above these levels of glucose. Conclusions- EVT improved stroke outcomes compared with standard treatment regardless of glucose levels, but the treatment effects were larger at lower glucose levels, with significant interaction effects persisting up to 90 to 100 mg/dL (5.0-5.5 mmol/L). Whether tight control of glucose improves the efficacy of EVT after large-vessel stroke warrants appropriate testing.
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Affiliation(s)
- Ángel Chamorro
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C., S.A., A.R.).,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.C., S.A., A.R.)
| | - Scott Brown
- Altair Biostatistics, St Louis Park, MN (S. Brown)
| | - Sergio Amaro
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C., S.A., A.R.).,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.C., S.A., A.R.)
| | - Michael D Hill
- Calgary Stroke Program, Departments of Clinical Neurosciences, Medicine, Community Health Sciences, and Radiology (M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Scotland, United Kingdom (K.W.M.)
| | - Diederik W J Dippel
- Department of Neurology (D.W.J.D., E.O., O.A.B.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wim van Zwam
- Department of Radiology (W.v.Z.), Maastricht University Medical Center Maastricht, the Netherlands
| | - Ken Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (K.B.)
| | - Gary A Ford
- Stroke Unit, Oxford University Hospitals and Division of Medical Sciences, Oxford University, United Kingdom (G.A.F.)
| | - Heleen M den Hertog
- Department of Neurology, Isala Klinieken, Zwolle, the Netherlands (H.M.d.H.).,Department of Neurology, Medisch Spectrum Twente, Enschede, Netherlands (H.M.d.H., E.O.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital (P.J.M.), University of Melbourne, Parkville, Australia
| | - Andrew M Demchuk
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology (A.M.D., M.A., M. Goyal, B.K.M.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Charles B L M Majoie
- Department of Radiology (C.B.L.M.M., O.A.B.), Academic Medical Center Amsterdam, the Netherlands
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, INSERM U 947 (S. Bracard), Université de Lorraine and University Hospital of Nancy, France
| | - Igor Sibon
- Stroke Unit University and University Hospital of CHU Bordeaux, France (I.S.)
| | | | | | - Aad van der Lugt
- Department of Radiology (A.v.d.L., O.A.B.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Elizabeth Osei
- Department of Neurology (D.W.J.D., E.O., O.A.B.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Neurology, Medisch Spectrum Twente, Enschede, Netherlands (H.M.d.H., E.O.)
| | - Arturo Renú
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C., S.A., A.R.).,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.C., S.A., A.R.)
| | - Sébastien Richard
- Department of Neurology, University Hospital of Nancy, France (S.R.)
| | - David Rodriguez-Luna
- Stroke Unit, Neurology Department, Vall d'Hebron University Hospital, Spain (D.R.-L.)
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Australia
| | - Anand Dixit
- University of Newcastle upon Tyne, United Kingdom (A.D.)
| | - Mohammed Almekhlafi
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology (A.M.D., M.A., M. Goyal, B.K.M.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Sandrine Deltour
- Urgences Cerebro-Vasculaires Sorbonne University and Pitié-Salpêtrière Hospital, APHP, Paris, France (S.D.)
| | - Jonathan Epstein
- INSERM CIC 1433 Clinical Epidemiology (J.E.), Université de Lorraine and University Hospital of Nancy, France
| | - Benoit Guillon
- Stroke Unit, University and University Hospital of Nantes, France (B.G.)
| | - Serge Bakchine
- Neurology-Stroke Unit University and University Hospital of Reims, France (S. Bakchine)
| | - Meritxell Gomis
- Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain (M. Gomis)
| | | | | | - Vivek Reddy
- Department of Neurology, University of Pittsburgh Medical Center, PA (V.R.)
| | - Gernot Rudel
- Department of Neurology, Klinikum Dortmund, Germany (G.R.)
| | - Yvo B W E M Roos
- Department of Neurology (Y.E.W.E.M.R.), Academic Medical Center Amsterdam, the Netherlands
| | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.)
| | - Hans-Christoph Diener
- Department of Neurology, University Hospital Essen University Duisburg-Essen, Germany (C.D.)
| | - Olvert A Berkhemer
- Department of Neurology (D.W.J.D., E.O., O.A.B.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology (A.v.d.L., O.A.B.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology (C.B.L.M.M., O.A.B.), Academic Medical Center Amsterdam, the Netherlands
| | - Geoffrey C Cloud
- Department of Clinical Neuroscience, Central Clinical School, Monash University and The Alfred Hospital, Melbourne, Australia (G.C.C.)
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (S.M.D.), University of Melbourne, Parkville, Australia
| | - Robert van Oostenbrugge
- Department of Neurology (R.v.O.), Maastricht University Medical Center Maastricht, the Netherlands
| | - Francis Guillemin
- INSERM CIC 1433 Clinical Epidemiology (F.G.), Université de Lorraine and University Hospital of Nancy, France
| | - Mayank Goyal
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology (A.M.D., M.A., M. Goyal, B.K.M.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Bijoy K Menon
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology (A.M.D., M.A., M. Goyal, B.K.M.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
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31
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Hoving JW, Marquering HA, Majoie CBLM, Yassi N, Sharma G, Liebeskind DS, van der Lugt A, Roos YB, van Zwam W, van Oostenbrugge RJ, Goyal M, Saver JL, Jovin TG, Albers GW, Davalos A, Hill MD, Demchuk AM, Bracard S, Guillemin F, Muir KW, White P, Mitchell PJ, Donnan GA, Davis SM, Campbell BCV. Volumetric and Spatial Accuracy of Computed Tomography Perfusion Estimated Ischemic Core Volume in Patients With Acute Ischemic Stroke. Stroke 2019; 49:2368-2375. [PMID: 30355095 DOI: 10.1161/strokeaha.118.020846] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [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: 02/07/2023]
Abstract
Background and Purpose- The volume of estimated ischemic core using computed tomography perfusion (CTP) imaging can identify ischemic stroke patients who are likely to benefit from reperfusion, particularly beyond standard time windows. We assessed the accuracy of pretreatment CTP estimated ischemic core in patients with successful endovascular reperfusion. Methods- Patients from the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) and EXTEND-IA TNK (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke) databases who had pretreatment CTP, >50% angiographic reperfusion, and follow-up magnetic resonance imaging at 24 hours were included. Ischemic core volume on baseline CTP data was estimated using relative cerebral blood flow <30% (RAPID, iSchemaView). Follow-up diffusion magnetic resonance imaging was registered to CTP, and the diffusion lesion was outlined using a semiautomated algorithm. Volumetric and spatial agreement (using Dice similarity coefficient, average Hausdorff distance, and precision) was assessed, and expert visual assessment of quality was performed. Results- In 120 patients, median CTP estimated ischemic core volume was 7.8 mL (IQR, 1.8-19.9 mL), and median diffusion lesion volume at 24 hours was 30.8 mL (IQR, 14.9-67.6 mL). Median volumetric difference was 4.4 mL (IQR, 1.2-12.0 mL). Dice similarity coefficient was low (median, 0.24; IQR, 0.15-0.37). The median precision (positive predictive value) of 0.68 (IQR, 0.40-0.88) and average Hausdorff distance (median, 3.1; IQR, 1.8-5.7 mm) indicated reasonable spatial agreement for regions estimated as ischemic core at baseline. Overestimation of total ischemic core volume by CTP was uncommon. Expert visual review revealed overestimation predominantly in white matter regions. Conclusions- CTP estimated ischemic core volumes were substantially smaller than follow-up diffusion-weighted imaging lesions at 24 hours despite endovascular reperfusion within 2 hours of imaging. This may be partly because of infarct growth. Volumetric CTP core overestimation was uncommon and not related to imaging-to-reperfusion time. Core overestimation in white matter should be a focus of future efforts to improve CTP accuracy.
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Affiliation(s)
- Jan W Hoving
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia.,Department of Radiology and Nuclear Medicine (J.W.H., H.A.M., C.B.L.M.M.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine (J.W.H., H.A.M., C.B.L.M.M.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands.,Department of Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine (J.W.H., H.A.M., C.B.L.M.M.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands
| | - Nawaf Yassi
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia.,The Florey Institute of Neuroscience and Mental Health (N.Y., G.A.D.), University of Melbourne, Parkville, Australia
| | - Gagan Sharma
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - David S Liebeskind
- Neurovascular Imaging Research Core, Department of Neurology (D.S.L.), University of California at Los Angeles
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.)
| | - Yvo B Roos
- Department of Neurology (Y.B.R.), Amsterdam UMC (Universitair Medische Centra), University of Amsterdam, the Netherlands
| | - Wim van Zwam
- Department of Radiology (W.v.Z.), Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, the Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology (R.J.v.O.), Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, the Netherlands
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, AB, Canada (M.G.)
| | - Jeffrey L Saver
- Department of Neurology (J.L.S.), University of California at Los Angeles
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, CA (T.G.J.)
| | | | - Antoni Davalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain (A.D.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, INSERM U 947 (S.B.), University of Lorraine and University Hospital of Nancy, France
| | - Francis Guillemin
- INSERM CIC-EC 1433 Clinical Epidemiology (F.G.), University of Lorraine and University Hospital of Nancy, France
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Scotland, United Kingdom (K.W.M.)
| | - Philip White
- Institute of Neuroscience, Newcastle University (P.W.), Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom.,Department of Neuroradiology (P.W.), Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia (P.J.M.)
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health (N.Y., G.A.D.), University of Melbourne, Parkville, Australia
| | - Stephen M Davis
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Bruce C V Campbell
- From the Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (J.W.H., N.Y., G.S., S.M.D., B.C.V.C.), University of Melbourne, Parkville, Australia
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32
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Chalos V, van der Ende N, Lingsma HF, Mulder MJ, Venema E, Dijkland SA, Berkhemer OA, Yoo A, Broderick JP, Palesch YY, Yeatts SD, Roos YB, van Oostenbrugge RJ, van Zwam W, Majoie CB, Van der Lugt A, Roozenbeek B, Dippel DW. Abstract TMP6: NIH Stroke Scale as the Primary Outcome Measure for Trials of Acute Treatment of Ischemic Stroke. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tmp6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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:
The 90-day modified Rankin Scale (mRS) is the most commonly used primary outcome measure in stroke treatment trials, but has drawbacks, including the potential loss of subjects due to prolonged follow-up. An alternative may be the NIH Stroke Scale (NIHSS) early after stroke, which is frequently used as a secondary outcome measure. The aim of this study was to evaluate whether the NIHSS assessed within one week after trial inclusion could serve as a primary outcome measure for trials of acute ischaemic stroke treatment.
Methods:
We used the Prentice criteria to evaluate NIHSS 1 day and 5-7 days after trial inclusion as primary outcome measures in two trials of endovascular treatment (EVT): the positive MR CLEAN and the neutral IMS III. The four Prentice criteria evaluate a surrogate endpoint against a true endpoint (Figure). We adjusted for age, baseline NIHSS, collateral score, and time of symptom onset to randomization.
Results:
The Prentice criteria were met for NIHSS at 1 day and 5-7 days in MR CLEAN (n=500). We found a significant treatment effect of EVT on the mRS and on the NIHSS at 1 day and 5-7 days. After adjustment for NIHSS at 1 day and 5-7 days, the effect of EVT on mRS decreased from common odds ratio 1·69 (95%CI: 1·22-2·33) to respectively 1·33 (95%CI: 0·95-1·85) and 1·21 (95%CI: 0·86-1·72). In IMS III (n=656) there was no treatment effect on NIHSS at 1 day (p=0.56) and 5-7 days (p=0.28), coinciding with the absence of a treatment effect on mRS.
Conclusion:
NIHSS is able to replace the mRS at 90 days as a measure of treatment effect. NIHSS within one week after trial inclusion may be used as a primary outcome measure in trials of acute ischemic stroke treatment, particularly in phase II(b) trials. This could minimize loss to follow-up, and reduce trial duration and costs.
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Affiliation(s)
- Vicky Chalos
- Stroke Cntr - Neurology, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Maxim J Mulder
- Stroke Cntr - Neurology, Erasmus MC, Rotterdam, Netherlands
| | - Esmee Venema
- Public Health, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Albert Yoo
- Dept of Interventional Neuroradiology, Texas Stroke Institute, Dallas-Fort Worth, TX
| | - Jospeh P Broderick
- Dept of Neurology and Rehabilitation Medicine, Univ of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH
| | - Yuko Y Palesch
- Dept of Public Health Sciences, Med Univ of South Carolina, Charleston, SC
| | - Sharon D Yeatts
- Dept of Public Health Sciences, Med Univ of South Carolina, Charleston, SC
| | - Yvo B Roos
- Neurology, Amsterdam UMC, Amsterdam, Netherlands
| | | | | | | | | | - Bob Roozenbeek
- Stroke Cntr - Neurology, Erasmus MC, Rotterdam, Netherlands
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33
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Heshmatollah A, Fransen P, Berkhemer O, Beumer D, van der Lugt A, Majoie C, Oostenbrugge R, van Zwam W, Koudstaal P, Roos Y, Dippel D. Endovascular thrombectomy in patients with acute ischaemic stroke and atrial fibrillation: a MR CLEAN subgroup analysis. EUROINTERVENTION 2017. [DOI: 10.4244/eij-d-16-00905] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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34
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Jansen I, Mulder M, Goldhoorn RJ, van der Lugt A, Marquering H, van Zwam W, Roos Y, Vos JA, Slump C, Schonewille W, Boiten J, Lyclama a Nijeholt G, Martens J, Hofmeijer J, van Oostenbrugge R, Dippel D, Majoie C. Abstract 35: MR CLEAN Registry: A Post-trial Multicenter Registry of Intra-arterial Treatment for Acute Ischemic Stroke in the Netherlands. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background & Purpose:
Intra-arterial therapy (IAT) is being implemented worldwide as the main treatment option for acute ischemic stroke (AIS). We wondered whether effectiveness and safety results that have been reported in randomized clinical trials can be reproduced in everyday clinical practice. We will report results of the Dutch National post MR CLEAN IAT registry including work flow parameters, primary and secondary outcomes, as well as serious adverse events.
Methods:
The MR CLEAN Registry is a prospective registry of all patients undergoing IAT for AIS in the Netherlands, started after completion of the MR CLEAN trial in March 2014. Registration was required for reimbursement. A core set was defined, with inclusion criteria similar to those of the MR CLEAN trial, including a proven anterior circulation occlusion and treatment possible withing 6 hours from onset. The primary study outcome is the score on the modified Rankin Scale (mRS) at 90 days. The secondary clinical outcome is NIHSS after 24 to 48 hours. Secondary radiological outcomes include the mTICI score on DSA and final infarct volume and major bleeding on follow up NCCT. We used a propensity weighted and an unadjusted ordinal logistic regression model to compare outcomes in the MR CLEAN Registry core and total dataset with the treatment arm of MR CLEAN.
Results:
Between March 2014 and August 2016 the inclusion rate of the MR CLEAN Registry has been increasing steadily to an average of 79 (SD 22) per month for a cumulative inclusion of 1548 patients in July 2016 (Figure 1).
Conclusions:
The MR CLEAN registry data is now being analyzed. Results will be reported at the conference.
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Affiliation(s)
- Ivo Jansen
- Academic Med Cntr, Amsterdam, Netherlands
| | | | | | | | | | - Wim van Zwam
- Maastricht Univ Med Cntr, Maastricht, Netherlands
| | - Yvo Roos
- Academic Med Cntr, Amsterdam, Netherlands
| | | | | | | | - Jelis Boiten
- Medisch Centrum Haaglanden, Den Haag, Netherlands
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35
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Campbell BC, van Zwam W, Goyal M, Menon BK, Dippel DW, Demchuk A, Dávalos A, Majoie CB, Brown S, Saver JL, Jovin TG, Hill MD, Mitchell PJ. Abstract 29: The Association Between General Anesthesia and Outcome of Endovascular Thrombectomy in Pooled Data From Five Randomized Trials. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.29] [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 and purpose:
General anesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies. We examined the association between GA and thrombectomy outcomes in pooled data from five randomized trials.
Methods:
Patient-level data were pooled from trials comparing endovascular thrombectomy (predominantly using stent retrievers) with standard care in anterior circulation ischemic stroke patients (HERMES Collaboration): MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA. The primary outcome was ordinal analysis of modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modeling with a random effect for trial incorporated in all models.
Results:
Of 1287 patients, 634 were allocated to endovascular thrombectomy and general anesthesia was used in 153/609 (25%) of endovascular-treated patients with anesthesia information available. Although dysphasic patients are sometimes felt to be less co-operative and require GA, the rate of GA was 25% in both right and left hemisphere patients. At baseline, GA and non-GA patients had similar age, NIHSS and time to randomization. Endovascular thrombectomy was associated with increased odds of improved functional outcome at 3 months, regardless of whether GA (cOR 1.73 95%CI 1.10-2.72, p=0.02) or non-GA (cOR 2.61 95%CI 2.01-3.40, p<0.001) was used. The odds of improved outcome were, however, significantly greater for those treated under non-GA (OR 1.59 95%CI 1.12-2.26, p=0.01). Pneumonia was more common in the GA group (16% vs 9% p=0.03). Rates of vessel perforation were similar in GA (0.7%) vs non-GA patients (1.8%, p=0.52). Delay between randomization and reperfusion was greater in GA versus non-GA patients (median 98 vs 75 min, p<0.001).
Conclusions:
Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment is still worthwhile in those who require anesthesia for medical reasons.
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Affiliation(s)
| | - Wim van Zwam
- Maastricht Univ Med Cntr, Cardiovascular Rsch Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Mayank Goyal
- Depts of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings Sch of Medicine, Univ of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Depts of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings Sch of Medicine, Univ of Calgary, Calgary, Canada
| | | | - Andrew Demchuk
- Depts of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings Sch of Medicine, Univ of Calgary, Calgary, Canada
| | | | | | | | - Jeffrey L Saver
- David Geffen Sch of Medicine, Univ of Los Angeles, Los Angeles, CA
| | - Tudor G Jovin
- Univ of Pittsburgh Med Cntr Stroke Institute, Presbyterian Univ Hosp, Pittsburgh, PA
| | - Michael D Hill
- Depts of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings Sch of Medicine, Univ of Calgary, Calgary, Canada
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36
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Dippel DW, Crijnen Y, Nouwens F, Lingsma HF, de Lau L, Visch E, van de Sandt-Koenderman M, Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Roos YB, van der Lugt A, van Oostenbrugge RJ, van Zwam W, Majoie CB. Abstract WP22: Differential Effect of Intra-arterial Treatment for Acute Ischemic Stroke on Motor versus Language Deficit. A Post-hoc Mr Clean Subgroup Analysis. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.wp22] [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:
Clinical observations suggest that language deficits in acute ischemic stroke do not respond as rapidly to reperfusion therapy as motor deficits. We tested for a differential effect of intra-arterial treatment with retrievable stents on recovery from aphasia and upper limb paresis in MR CLEAN.
Hypothesis:
The early effect of IAT on recovery from language and motor deficits is similar in size.
Methods:
All patients with aphasia who were randomized in MR CLEAN were included. Primary outcomes were the score on the NIH stroke scale item for upper extremity paresis contralateral to the affected hemisphere, and the score for language, at 24 hours and 5-7 days after treatment. We estimated the effect of IAT on the shift on these item scores and tested for a differential effect of IAT on language versus motor recovery, by introducing a multiplicative term in a multilevel multivariable ordinal logistic regression model.
Results:
In total, 288 patients had an aphasia score of 1 or more. Of these 126 (44%) were assigned to IAT and 162 (56%) to no IAT. The common odds ratio (cOR) for improvement in language and motor score at 24 hours was 1.68 (1.06 to 2.67) and 2.51 (1.57 to 4.03) (p=0.006). At 5-7 days the cOR was 1.87 (1.18 to 2.98) for aphasia score and 2.41 (1.47 to 3.95) for motor deficit (p=0.011). The proportion of patients with good recovery at 5-7 days was similar (Figure).
Conclusion:
The early effect of IAT on language deficit is smaller than the effect on motor deficit, but final recovery after 1 week is similar.
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Affiliation(s)
| | - Yvette Crijnen
- Neurology, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Femke Nouwens
- Neurology, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | | | - Lonneke de Lau
- Neurology, Slotervaart ZIekenhuis, Amsterdam, Netherlands
| | - Evy Visch
- Neurology, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | | | | | - Puck S Fransen
- Neurology, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Debbie Beumer
- Neurology, Maastricht Univ Med Cntr, Maastricht, Netherlands
| | | | - Yvo B Roos
- Neurology, Academic Med Cntr, Amsterdam, Netherlands
| | | | | | - Wim van Zwam
- Radiology, Maastricht Univ Med Cntr, Maastricht, Netherlands
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37
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Wahlgren N, Moreira T, Michel P, Steiner T, Jansen O, Cognard C, Mattle HP, van Zwam W, Holmin S, Tatlisumak T, Petersson J, Caso V, Hacke W, Mazighi M, Arnold M, Fischer U, Szikora I, Pierot L, Fiehler J, Gralla J, Fazekas F, Lees KR. Mechanical thrombectomy in acute ischemic stroke: Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN. Int J Stroke 2015; 11:134-47. [DOI: 10.1177/1747493015609778] [Citation(s) in RCA: 271] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The original version of this consensus statement on mechanical thrombectomy was approved at the European Stroke Organisation (ESO)-Karolinska Stroke Update conference in Stockholm, 16–18 November 2014. The statement has later, during 2015, been updated with new clinical trials data in accordance with a decision made at the conference. Revisions have been made at a face-to-face meeting during the ESO Winter School in Berne in February, through email exchanges and the final version has then been approved by each society. The recommendations are identical to the original version with evidence level upgraded by 20 February 2015 and confirmed by 15 May 2015. The purpose of the ESO-Karolinska Stroke Update meetings is to provide updates on recent stroke therapy research and to discuss how the results may be implemented into clinical routine. Selected topics are discussed at consensus sessions, for which a consensus statement is prepared and discussed by the participants at the meeting. The statements are advisory to the ESO guidelines committee. This consensus statement includes recommendations on mechanical thrombectomy after acute stroke. The statement is supported by ESO, European Society of Minimally Invasive Neurological Therapy (ESMINT), European Society of Neuroradiology (ESNR), and European Academy of Neurology (EAN).
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Affiliation(s)
- Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Tiago Moreira
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Michel
- Département des Neurosciences Cliniques, Lausanne, Switzerland
| | - Thorsten Steiner
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH, Kiel, Germany
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Turgut Tatlisumak
- Institute of Neuroscience and Physiology, Sahlgrenska Academy of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jesper Petersson
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
- Department of Neurology, Lund University, Lund, Sweden
| | - Valeria Caso
- Stroke Unit, Santa Maria Hospital, University of Perugia, Perugia, Italy
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Mikael Mazighi
- Pole Neurosensoriel Tête et Cou, Hôpital Lariboisière, Paris, France
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Istvan Szikora
- Department of Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Laurent Pierot
- Service de Radiologie, Hôpital Maison-Blanche, Reims, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Franz Fazekas
- Department of Neurology, Medical University Graz, Graz, Austria
| | - Kennedy R Lees
- Department of Cerebrovascular Medicine, University of Glasgow, Glasgow, Scotland, UK
- Acute Stroke Unit, Western Infirmary, Glasgow, Scotland, UK
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