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Germans MR, Tjerkstra MA, Post R, Brenner A, Vergouwen MDI, Rinkel GJ, Roos YB, van den Berg R, Coert BA, Vandertop WP, Verbaan D. Impact of time to start of tranexamic acid treatment on rebleed risk and outcome in aneurysmal subarachnoid hemorrhage. Eur Stroke J 2024:23969873241246591. [PMID: 38606724 DOI: 10.1177/23969873241246591] [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: 04/13/2024] Open
Abstract
INTRODUCTION The ULTRA-trial investigated effectiveness of ultra-early administration of tranexamic acid (TXA) in subarachnoid hemorrhage (SAH) and showed that TXA reduces the risk of rebleeding without concurrent improvement in clinical outcome. Previous trials in bleeding conditions, distinct from SAH, have shown that time to start of antifibrinolytic treatment influences outcome. This post-hoc analysis of the ULTRA-trial investigates whether the interval between hemorrhage and start of TXA impacts the effect of TXA on rebleeding and functional outcome following aneurysmal SAH. PATIENTS AND METHODS A post-hoc comparative analysis was conducted between aneurysmal SAH patients of the ULTRA-trial, receiving TXA and usual care to those receiving usual care only. We assessed confounders, hazard ratio (HR) of rebleeding and odds ratio (OR) of good outcome (modified Rankin Scale 0-3) at 6 months, and investigated the impact of time between hemorrhage and start of TXA on the treatment effect, stratified into time categories (0-3, 3-6 and >6 h). RESULTS Sixty-four of 394 patients (16.2%) in the TXA group experienced a rebleeding, compared to 83 of 413 patients (19.9%) with usual care only (HR 0.86, 95% confidence interval (CI): 0.62-1.19). Time to start of TXA modifies the effect of TXA on rebleeding rate (p < 0.001), with a clinically non-relevant reduction observed only when TXA was initiated after 6 h (absolute rate reduction 1.4%). Tranexamic acid treatment showed no effect on good outcome (OR 0.96, 95% CI: 0.72-1.27) with no evidence of effect modification on the time to start of TXA (p = 0.53). DISCUSSION AND CONCLUSIONS This study suggests that the effect of TXA on rebleeding is modified by time to treatment, providing a protective, albeit clinically non-relevant, effect only when started after 6 h. No difference in functional outcome was seen. Routine TXA treatment in the aneurysmal SAH population, even within a specified time frame, is not recommended to improve functional outcome.
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Affiliation(s)
- Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Amy Brenner
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mervyn DI Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriël Je Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Yvo Bwem Roos
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
- Department of Neurology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, The Netherlands
| | - René van den Berg
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
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LeCouffe NE, Treurniet KM, Kappelhof M, Jansen IG, Boers M, Marquering HA, Beenen LF, Boiten J, van Zwam WH, Yo LS, Majoie CB, Roos YB, Emmer BJ, Coutinho JM. Outcome of patients with multivessel occlusion stroke after endovascular treatment. Eur Stroke J 2023:23969873231216811. [PMID: 38102770 DOI: 10.1177/23969873231216811] [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: 12/17/2023] Open
Abstract
INTRODUCTION Little is known about the implications of multivessel occlusions (MVO) in large vessel occlusion stroke patients who undergo endovascular treatment (EVT). PATIENTS AND METHODS We report data from the MR CLEAN Registry: a prospective, observational study on all stroke patients who underwent EVT in the Netherlands (March 2014-November 2017). We included patients with an intracranial target occlusion in the anterior circulation. An MVO was defined as an MCA occlusion (M1/M2) or intracranial ICA/ICA-T occlusion, with a concurrent second occlusion in the ACA or PCA territory confirmed on baseline CTA. To compare outcomes, we performed a 10:1 propensity score matching analysis with a logistic regression model including potential confounders. Outcome measures included 90-day functional outcome (modified Rankin Scale, mRS) and mortality. RESULTS Of 2946 included patients, 71 patients (2.4%) had an MVO (87% concurrent ACA occlusion, 10% PCA occlusion, 3% ⩾3 occlusions). These patients were matched to 71 non-MVO patients. Before matching, MVO patients had a higher baseline NIHSS (median 18 vs 16, p = 0.001) and worse collateral status (absent collaterals: 17% vs 6%, p < 0.001) compared to non-MVO patients. After matching, MVO patients had worse functional outcome at 90 days (median mRS 5 vs 3, cOR 0.39; 95%CI 0.25-0.62). Mortality was higher in MVO patients (46% vs 27%, OR 2.11, 95%CI 1.24-3.57). DISCUSSION AND CONCLUSION MVOs on baseline imaging were uncommon in LVO stroke patients undergoing EVT, but were associated with poor functional outcome.
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Affiliation(s)
- Natalie E LeCouffe
- Amsterdam UMC, Amsterdam Neuroscience, Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands
| | - Kilian M Treurniet
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, The Netherlands
- Haaglanden MC, Department of Radiology, The Hague, The Netherlands
| | - Manon Kappelhof
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Ivo Gh Jansen
- Amsterdam UMC, Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands
| | - Merel Boers
- Amsterdam UMC, Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Amsterdam UMC, Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo Fm Beenen
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Jelis Boiten
- Haaglanden MC, Department of Neurology, The Hague, The Netherlands
| | - Wim H van Zwam
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Department of Radiology, Maastricht, The Netherlands
| | - Lonneke Sf Yo
- Catharina Hospital Eindhoven, Department of Radiology, Eindhoven, The Netherlands
| | - Charles Blm Majoie
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo Bwem Roos
- Amsterdam UMC, Amsterdam Neuroscience, Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J Emmer
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Amsterdam UMC, Amsterdam Neuroscience, Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands
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Flint AC, Chan SL, Edwards NJ, Rao VA, Klingman JG, Nguyen-Huynh MN, Yan B, Mitchell PJ, Davis SM, Campbell BC, Dippel DW, Roos YB, van Zwam WH, Saver JL, Kidwell CS, Hill MD, Goyal M, Demchuk AM, Bracard S, Bendszus M, Donnan GA, On Behalf Of The Vista-Endovascular Collaboration. Outcome prediction in large vessel occlusion ischemic stroke with or without endovascular stroke treatment: THRIVE-EVT. Int J Stroke 2023; 18:331-337. [PMID: 35319310 DOI: 10.1177/17474930221092262] [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: 11/17/2022]
Abstract
INTRODUCTION The THRIVE score and the THRIVE-c calculation are validated ischemic stroke outcome prediction tools based on patient variables that are readily available at initial presentation. Randomized controlled trials (RCTs) have demonstrated the benefit of endovascular treatment (EVT) for many patients with large vessel occlusion (LVO), and pooled data from these trials allow for adaptation of the THRIVE-c calculation for use in shared clinical decision making regarding EVT. METHODS To extend THRIVE-c for use in the context of EVT, we extracted data from the Virtual International Stroke Trials Archive (VISTA) from 7 RCTs of EVT. Models were built in a randomly selected development cohort using logistic regression that included the predictors from THRIVE-c: age, NIH Stroke Scale (NIHSS) score, presence of hypertension, diabetes mellitus, and/or atrial fibrillation, as well as randomization to EVT and, where available, the Alberta Stroke Program Early CT Score (ASPECTS). RESULTS Good outcome was achieved in 366/787 (46.5%) of subjects randomized to EVT and in 236/795 (29.7%) of subjects randomized to control (P < 0.001), and the improvement in outcome with EVT was seen across age, NIHSS, and THRIVE-c good outcome prediction. Models to predict outcome using THRIVE elements (age, NIHSS, and comorbidities) together with EVT, with or without ASPECTS, had similar performance by ROC analysis in the development and validation cohorts (THRIVE-EVT ROC area under the curve (AUC) = 0.716 in development, 0.727 in validation, P = 0.30; THRIVE-EVT + ASPECTS ROC AUC = 0.718 in development, 0.735 in validation, P = 0.12). CONCLUSION THRIVE-EVT may be used alongside the original THRIVE-c calculation to improve outcome probability estimation for patients with acute ischemic stroke, including patients with or without LVO, and to model the potential improvement in outcomes with EVT for an individual patient based on variables that are available at initial presentation. Online calculators for THRIVE-c estimation are available at www.thrivescore.org and www.mdcalc.com/thrive-score-for-stroke-outcome.
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Affiliation(s)
- Alexander C Flint
- Division of Research and Department of Neuroscience, Kaiser Permanente, Redwood City, CA, USA
| | - Sheila L Chan
- Division of Research and Department of Neuroscience, Kaiser Permanente, Redwood City, CA, USA
| | - Nancy J Edwards
- Division of Research and Department of Neuroscience, Kaiser Permanente, Redwood City, CA, USA
| | - Vivek A Rao
- Division of Research and Department of Neuroscience, Kaiser Permanente, Redwood City, CA, USA
| | | | | | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Peter J Mitchell
- Department of Radiology, The University of Melbourne, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Bruce Cv Campbell
- Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Diederik W Dippel
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Serge Bracard
- Department of Neuroradiology, University of Lorraine, Nancy, France
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Geoffrey A Donnan
- Melbourne Brain Centre at Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
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Abstract
BACKGROUND Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably related to the dissolution of the blood clot at the site of the aneurysm rupture by natural fibrinolytic activity. This review is an update of previously published Cochrane Reviews. OBJECTIVES To assess the effects of antifibrinolytic treatment in people with aneurysmal subarachnoid haemorrhage. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (May 2022), CENTRAL (in the Cochrane Library 2021, Issue 1), MEDLINE (December 2012 to May 2022), and Embase (December 2012 to May 2022). In an effort to identify further published, unpublished, and ongoing studies, we searched reference lists and trial registers, performed forward tracking of relevant references, and contacted drug companies (the latter in previous versions of this review). SELECTION CRITERIA Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid, or an equivalent) with control in people with subarachnoid haemorrhage of suspected or proven aneurysmal cause. DATA COLLECTION AND ANALYSIS Two review authors (MRG & WJD) independently selected trials for inclusion, and extracted the data for the current update. In total, three review authors (MIB & MRG in the previous update; MRG & WJD in the current update) assessed risk of bias. For the primary outcome, we dichotomised the outcome scales into good and poor outcome, with poor outcome defined as death, vegetative state, or (moderate) severe disability, assessed with either the Glasgow Outcome Scale or the Modified Rankin Scale. We assessed death from any cause, rates of rebleeding, delayed cerebral ischaemia, and hydrocephalus per treatment group. We expressed effects as risk ratios (RR) with 95% confidence intervals (CI). We used random-effects models for all analyses. We assessed the quality of the evidence with GRADE. MAIN RESULTS We included one new trial in this update, for a total of 11 included trials involving 2717 participants. The risk of bias was low in six studies. Five studies were open label, and we rated them at high risk of performance bias. We also rated one of these studies at high risk for attrition and reporting bias. Five trials reported on poor outcome (death, vegetative state, or (moderate) severe disability), with a pooled risk ratio (RR) of 1.03 (95% confidence interval (CI) 0.94 to 1.13; P = 0.53; 5 trials, 2359 participants; high-quality evidence), which showed no difference between groups. All trials reported on death from all causes, which showed no difference between groups, with a pooled RR of 1.02 (95% CI 0.90 to 1.16; P = 0.77; 11 trials, 2717 participants; high-quality evidence). In trials that combined short-term antifibrinolytic treatment (< 72 hours) with preventative measures for delayed cerebral ischaemia, the RR for poor outcome was 0.98 (95% CI 0.81 to 1.18; P = 0.83; 2 trials, 1318 participants; high-quality evidence). Antifibrinolytic treatment reduced the risk of rebleeding, reported at the end of follow-up (RR 0.65, 95% CI 0.47 to 0.91; P = 0.01; 11 trials, 2717 participants; absolute risk reduction 7%, 95% CI 3 to 12%; moderate-quality evidence), but there was heterogeneity (I² = 59%) between the trials. The pooled RR for delayed cerebral ischaemia was 1.27 (95% CI 1.00 to 1.62; P = 0.05; 7 trials, 2484 participants; moderate-quality evidence). However, this effect was less extreme after the implementation of ischaemia preventative measures and < 72 hours of treatment (RR 1.10, 95% CI 0.83 to 1.46; P = 0.49; 2 trials, 1318 participants; high-quality evidence). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus (RR 1.09, 95% CI 0.99 to 1.20; P = 0.09; 6 trials, 1992 participants; high-quality evidence). AUTHORS' CONCLUSIONS The current evidence does not support the routine use of antifibrinolytic drugs in the treatment of people with aneurysmal subarachnoid haemorrhage. More specifically, early administration with concomitant treatment strategies to prevent delayed cerebral ischaemia does not improve clinical outcome. There is sufficient evidence from multiple randomised controlled trials to incorporate this conclusion in treatment guidelines.
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Affiliation(s)
- Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Wouter J Dronkers
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Merih I Baharoglu
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Yvo Bwem Roos
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
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van den Bos N, van den Berg SA, Caupain CM, Pols JA, van Middelaar T, Chalos V, Dippel DW, Roos YB, Kappelhof M, Nederkoorn PJ. Patient and proxies' attitudes towards deferred consent in randomised trials of acute treatment for stroke: A qualitative survey. Eur Stroke J 2022; 6:395-402. [PMID: 35342818 PMCID: PMC8948520 DOI: 10.1177/23969873211057421] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/10/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Deferral of consent for participation in a clinical study is a relatively novel procedure, in which informed consent is obtained after randomisation and study treatment. Deferred consent can be used in emergency situations, where small therapeutic time windows limit possibilities for patients to provide informed consent. We aimed to investigate patients' or their proxies' experiences and opinions regarding deferred consent in acute stroke randomised trials. Patients and methods For this qualitative study, Dutch Collaboration for New Treatments of Acute Stroke (CONTRAST) trial participants were selected. Study participants were either patients or their proxies who provided consent and were selected with theoretical sampling based on patient characteristics. Semi-structured interviews were conducted face-to-face or by telephone. Themes and subthemes were iteratively defined. Results Twenty of the 23 interviewed participants (16 patients and 7 proxies) considered deferred consent acceptable. The received study treatment and consent conversation were remembered by 18 participations, although the concept of randomisation and treatment comparison were generally not well understood. Sixteen participants felt capable of overseeing the decision to give deferred consent. Distress in the first days after stroke, lack of understanding and neurological deficits were reasons for feeling incapable of providing consent. Four participants would have preferred a different timing of the consent conversation, of whom two prior to treatment. Conclusion Our study found that deferred consent was considered acceptable by most study participants who provided consent for acute stroke randomised trials. Though they felt capable, the recall and comprehension of consent were overall limited.
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Affiliation(s)
- Noa van den Bos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sophie A van den Berg
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Catalina Mm Caupain
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeannette Aj Pols
- Department of Ethics, Law and Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anthropology, University of Amsterdam, The Netherlands
| | - Tessa van Middelaar
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Bernsen MLE, Kauw F, Martens JM, van der Lugt A, Yo LS, van Walderveen MA, Roos YB, van der Worp HB, Dankbaar JW, Hofmeijer J. Malignant infarction after endovascular treatment: Incidence and prediction. Int J Stroke 2021; 17:198-206. [PMID: 33724092 DOI: 10.1177/17474930211006290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Early prediction of malignant infarction may guide treatment decisions. For patients who received endovascular treatment, the risk of malignant infarction is unknown and risk factors are unrevealed. AIMS The objective of this study is to estimate the incidence of malignant infarction after endovascular treatment in patients with an occlusion of the anterior circulation, to identify independent risk factors, and to establish a model for prediction. METHODS We analyzed patients who received endovascular treatment for a large vessel occlusion in the anterior circulation within 6.5 h after symptom onset, included in the Dutch MR CLEAN Registry between March 2014 and June 2016. We compared patients with and without malignant infarction. Candidate predictors were incorporated in a multivariable binary logistic regression model. The final prediction model was established using backward elimination. Discrimination and calibration were evaluated with the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test. RESULTS Of 1445 patients, 82 (6%) developed malignant infarction. Independent predictors were lower age, higher National Institutes of Health Stroke Scale (NIHSS), lower alberta stroke program early CT score (ASPECTS), internal carotid artery occlusion, lower collateral score, longer times from onset to groin puncture, and unsuccessful reperfusion. The AUROC of a prediction model combining these features was 0.83 (95% confidence interval (CI): 0.79-0.88) and the Hosmer-Lemeshow test indicated appropriate calibration (P = 0.937). CONCLUSION The risk of malignant infarction after endovascular treatment started within 6.5 h of stroke onset is approximately 6%. Successful reperfusion decreases the risk. A prediction model combining easily retrievable measures of age, ASPECTS, collateral status, and reperfusion shows good discrimination between patients who will develop malignant infarction and those who will not.
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Affiliation(s)
| | - Frans Kauw
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasper M Martens
- Department of Radiology & Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Lonneke Sf Yo
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Yvo Bwem Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - H Bart van der Worp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands.,Faculty of Science and Technology, Technical Medical Center, University of Twente, Enschede, The Netherlands
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Guglielmi V, Rinkel LA, Groeneveld NS, Lobé NH, Boekholdt SM, Bouma BJ, Beenen LF, Marquering HA, Majoie CB, Roos YB, van Randen A, Planken RN, Coutinho JM. Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke-rationale and study design. Eur Stroke J 2021; 5:441-448. [PMID: 33598563 PMCID: PMC7856589 DOI: 10.1177/2396987320962911] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/23/2020] [Indexed: 11/16/2022] Open
Abstract
Rationale About one-third of ischaemic strokes are caused by cardioembolism, and a substantial proportion of cryptogenic strokes likely also originate from the heart or aortic arch. Early determination of aetiology is important to optimise management. Computed Tomography-angiography of the heart is emerging as an alternative to echocardiography to detect cardio-aortic sources of embolism in stroke patients, but its diagnostic yield in acute ischaemic stroke has not been thoroughly assessed.Hypothesis: We hypothesise that electrocardiography-gated computed tomography-angiography of the heart and aortic arch, acquired in the acute phase in patients with ischaemic stroke, has a higher diagnostic yield than transthoracic echocardiography as a first-line screening method for detection of cardio-aortic sources of embolism. Methods and design Mind the Heart is a single-centre prospective observational cohort study. We will include consecutive adult patients with acute ischaemic stroke who are potentially eligible for reperfusion therapy. Patients undergo non-electrocardiography-gated computed tomography-angiography of the aortic arch, cervical and intracranial arteries, directly followed by prospective sequential electrocardiography-gated cardiac computed tomography-angiography. Routine work-up for cardioembolism including 12-leads electrocardiography, Holter electrocardiography and transthoracic echocardiography is performed as soon as possible. The primary endpoint is the proportion of patients with a predefined high-risk cardio-aortic source of embolism on computed tomography-angiography versus transthoracic echocardiography in patients who underwent both investigations. Based on an expected 5% additional yield of computed tomography-angiography, a sample size of 450 patients is required. Conclusions The Mind the Heart study will generate a reliable estimate of the diagnostic yield of echocardiography-gated cardio-aortic computed tomography-angiography performed in the acute phase of ischaemic stroke.
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Affiliation(s)
- Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Nick Hj Lobé
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo Fm Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adrienne van Randen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Dessens FM, Groot AE, van der Veen B, Treurniet KM, Majoie CB, Driessen-Waaijer A, Weinstein HC, Roos YB, Van den Berg-Vos RM, Coutinho JM, van Schaik SM. The association between computed tomography angiography timing and workflow times in patients with acute ischemic stroke. Int J Stroke 2020; 16:534-541. [PMID: 32996877 DOI: 10.1177/1747493020962236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In most hospitals, computed tomography angiography (CTA) is nowadays routinely performed in patients with acute ischemic stroke. However, it is unclear whether CTA is best performed before or after start of intravenous thrombolysis (IVT), since acquisition of CTA before IVT may prolong door-to-needle times, while acquisition after IVT may prolong door-to-groin times in patients undergoing endovascular treatment. METHODS We performed a before-versus-after study (CTA following IVT, period I and CTA prior to IVT, period II), consisting of two periods of one year each. This study is based on a prospective registry of consecutive patients treated with IVT in two collaborating high-volume stroke centers; one primary stroke center and one comprehensive stroke center. The primary outcome was door-to-needle times. Secondary outcomes included door-to-groin times. Quantile regression analyses were performed to evaluate the association between timing of CTA and workflow times, adjusted for prognostic factors. RESULTS A total of 519 patients received IVT during the study period (246 in period I, 273 in period II). In the adjusted analysis, we found a nonsignificant 1.13 min median difference in door-to-needle times (95% confidence interval: 1.03-3.29). Door-to-groin times was significantly shorter in period II in both unadjusted and adjusted analysis with the latter showing a 19.16 min median difference (95% confidence interval: 3.08-35.24). CONCLUSIONS CTA acquisition prior to start of IVT did not adversely affect door-to-needle times. However, a significantly shorter door-to-groin times was observed in endovascular treatment eligible patients. Performing CTA prior to start of IVT seems the preferred strategy.
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Affiliation(s)
| | - Adrien E Groot
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bas van der Veen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kilian M Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | | | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Renske M Van den Berg-Vos
- Department of Neurology, OLVG, Amsterdam, the Netherlands.,Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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9
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van de Graaf RA, Zinkstok SM, Chalos V, Goldhoorn RJB, Majoie CB, van Oostenbrugge RJ, van der Lugt A, Dippel DW, Roos YB, Lingsma HF, van Es AC, Roozenbeek B. Prior antiplatelet therapy in patients undergoing endovascular treatment for acute ischemic stroke: Results from the MR CLEAN Registry. Int J Stroke 2020; 16:476-485. [PMID: 32791940 PMCID: PMC8193619 DOI: 10.1177/1747493020946975] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Antiplatelet therapy may increase the risk of symptomatic intracranial hemorrhage after endovascular treatment for ischemic stroke but may also have a beneficial effect on functional outcome. The aim of this study is to compare safety and efficacy outcomes after endovascular treatment in patients with and without prior antiplatelet therapy. Methods We analyzed patients registered in the MR CLEAN Registry between March 2014 and November 2017, for whom data on antiplatelet therapy were available. We used propensity score nearest-neighbor matching with replacement to balance the probability of receiving prior antiplatelet therapy between the prior antiplatelet therapy and no prior antiplatelet therapy group and adjusted for baseline prognostic factors to compare these groups. Primary outcome was symptomatic intracranial hemorrhage. Secondary outcomes were 90-day functional outcome (modified Rankin Scale), successful reperfusion (extended thrombolysis in cerebral infarction score ≥2B) and 90-day mortality. Results Thirty percent (n = 937) of the 3154 patients were on prior antiplatelet therapy, who were matched to 477 patients not on prior antiplatelet therapy. Symptomatic intracranial hemorrhage occurred in 74/937 (7.9%) patients on prior antiplatelet therapy and in 27/477 (5.6%) patients without prior antiplatelet therapy adjusted odds ratio 1.47, 95% confidence interval 0.86–2.49. No associations were found between prior antiplatelet therapy and functional outcome (adjusted common odds ratio 0.87, 95% confidence interval 0.65–1.16), successful reperfusion (adjusted odds ratio 1.23, 95% confidence interval 0.77–1.97), or 90-day mortality (adjusted odds ratio 1.15, 95% confidence interval 0.86–1.54). Conclusion We found no evidence of an association of prior antiplatelet therapy with the risk of symptomatic intracranial hemorrhage after endovascular treatment, nor on functional outcome, reperfusion, or mortality. A substantial beneficial or detrimental effect of antiplatelet therapy on clinical outcome cannot be excluded. A randomized clinical trial comparing antiplatelet therapy versus no antiplatelet therapy is needed.
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Affiliation(s)
- Rob A van de Graaf
- Department of Neurology, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sanne M Zinkstok
- Department of Neurology, 3913Tergooi, Hilversum, The Netherlands
| | - Vicky Chalos
- Department of Neurology, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Public Health, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan B Goldhoorn
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Location AMC, Amsterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Adriaan Cgm van Es
- Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
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10
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Smaal JA, de Ridder IR, Heshmatollah A, van Zwam WH, Dippel D, Majoie CB, Brown S, Goyal M, Campbell B, Muir KW, Demchuck AM, Davalos A, Jovin TG, Mitchell PJ, White P, Saver JL, Hill MD, Roos YB, van der Lugt A, van Oostenbrugge RJ. Effect of atrial fibrillation on endovascular thrombectomy for acute ischemic stroke. A meta-analysis of individual patient data from six randomised trials: Results from the HERMES collaboration. Eur Stroke J 2020; 5:245-251. [PMID: 33072878 PMCID: PMC7538768 DOI: 10.1177/2396987320923447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background Atrial fibrillation is an important risk factor for ischemic stroke, and is
associated with an increased risk of poor outcome after ischemic stroke.
Endovascular thrombectomy is safe and effective in acute ischemic stroke
patients with large vessel occlusion of the anterior circulation. This
meta-analysis aims to investigate whether there is an interaction between
atrial fibrillation and treatment effect of endovascular thrombectomy, and
secondarily whether atrial fibrillation is associated with worse outcome in
patients with ischemic stroke due to large vessel occlusion. Methods Individual patient data were from six of the recent randomised clinical
trials (MR CLEAN, EXTEND-IA, REVASCAT, SWIFT PRIME, ESCAPE, PISTE) in which
endovascular thrombectomy plus standard care was compared to standard care
alone. Primary outcome measure was the shift on the modified Rankin scale
(mRS) at 90 days. Secondary outcomes were functional independence (mRS 0–2)
at 90 days, National Institutes of Health Stroke Scale score at 24 h,
symptomatic intracranial hemorrhage and mortality at 90 days. The primary
effect parameter was the adjusted common odds ratio, estimated with ordinal
logistic regression (shift analysis); treatment effect modification of
atrial fibrillation was assessed with a multiplicative interaction term. Results Among 1351 patients, 447 patients had atrial fibrillation, 224 of whom were
treated with endovascular thrombectomy. We found no interaction of atrial
fibrillation with treatment effect of endovascular thrombectomy for both
primary (p-value for interaction: 0.58) and secondary
outcomes. Regardless of treatment allocation, we found no difference in
primary outcome (mRS at 90 days: aOR 1.11 (95% CI 0.89–1.38) and secondary
outcomes between patients with and without atrial fibrillation. Conclusion We found no interaction of atrial fibrillation on treatment effect of
endovascular thrombectomy, and no difference in outcome between large vessel
occlusion stroke patients with and without atrial fibrillation.
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Affiliation(s)
- J A Smaal
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - I R de Ridder
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - A Heshmatollah
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - W H van Zwam
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Dwj Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - C B Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - S Brown
- Altair Biostatistics, St Louis Park, MN, USA
| | - M Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Bcv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - K W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - A M Demchuck
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - A Davalos
- Department of Neuroscience, University Autònoma de Barcelona, Spain
| | - T G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - P J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - P White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - J L Saver
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - M D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Y B Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - A van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - R J van Oostenbrugge
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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11
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Yang P, Treurniet KM, Zhang L, Zhang Y, Li Z, Xing P, Zhang Y, Zhang P, Wang H, Hong B, Dippel DW, Roos YB, Majoie CB, Deng B, Liu J. Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial (DIRECT-MT)-Protocol. Int J Stroke 2019; 15:689-698. [PMID: 31663831 DOI: 10.1177/1747493019882837] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [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: 01/10/2023]
Abstract
RATIONALE Intravenous thrombolysis combined with mechanical thrombectomy (MT) has been proven safe and clinical effective in patients with acute ischemic stroke of anterior circulation large vessel occlusion. However, despite reperfusion, a considerable proportion of patients do not recover. Incidence of symptomatic intracerebral hemorrhage was similar between patients treated with the combination of intravenous thrombolysis and MT, as compared to intravenous thrombolysis alone, suggesting that this complication should be attributed to pre-treatment with intravenous thrombolysis. Conversely, intravenous thrombolysis may be beneficial in patients with small clots occluding intracranial arteries with underlying intracranial atherosclerotic disease, not accessible for MT. AIM To assess whether direct MT is non-inferior compared to combined intravenous thrombolysis plus MT in patients with AIS due to an anterior circulation large vessel occlusion, and to assess treatment effect modification by presence of intracranial atherosclerotic disease. SAMPLE SIZE Aim to randomize 636 patients 1:1 to receive direct MT (intervention) or combined intravenous thrombolysis plus MT (control). DESIGN This is a multicenter, prospective, open label parallel group trial with blinded outcome assessment (PROBE design) assessing non-inferiority of direct MT compared to combined intravenous thrombolysis plus MT. OUTCOMES The primary outcome is the score on the modified Rankin Scale assessed blindly at 90 (±14) days. An common odds ratio, adjusted for the prognostic factors (age, NIHSS, collateral score), representing the shift on the 6-category mRS scale measured at three months, estimated with ordinal logistic regression, will be the primary effect parameter. Non-inferiority is established if the lower boundary of the 95% confidence interval does not cross 0.8. DISCUSSION DIRECT-MT could result in improved therapeutic efficiency and cost reduction in treatment of anterior circulation large vessel occlusion stroke.
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Affiliation(s)
- Pengfei Yang
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Kilian M Treurniet
- Radiology & Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Lei Zhang
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurology, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Zifu Li
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Pengfei Xing
- Neurology, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Ping Zhang
- Neurology, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Hao Wang
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Bo Hong
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Diederik Wj Dippel
- Erasmus MC University Medical Center, Neurology and Stroke Center, Rotterdam, The Netherlands
| | - Yvo Bwem Roos
- Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Radiology & Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Benqiang Deng
- Neurology, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
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12
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Guglielmi V, Groeneveld NS, Posthuma L, Groot AE, Majoie CB, Talacua H, Kaya A, Boekholdt SM, Planken RN, Roos YB, Coutinho JM. Aortic dissection masquerading as a code stroke: A single-centre cohort study. Eur Stroke J 2019; 5:56-62. [PMID: 32232170 PMCID: PMC7092736 DOI: 10.1177/2396987319883713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/27/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Data on the incidence of acute aortic dissection in the code stroke population are scarce. We report estimated incidence, clinical manifestations, treatment and outcomes of patients with an acute aortic dissection in a code stroke cohort from a comprehensive stroke centre. Patients and methods We used data from a single-centre prospective registry of consecutive adult patients who presented to the emergency department between 2015 and 2018 with neurological deficits suggestive of an acute stroke (‘code stroke’). All patients routinely underwent non-contrast computed tomography of the brain and computed tomography-angiography of the aortic arch, cervical and intracranial arteries. Results Of 2874 code stroke patients, 1563 (54.4%) had acute ischaemia (ischaemic stroke or transient ischaemic attack). Fifteen patients (0.5% of code stroke patients and 0.8% of patients with acute ischaemia) had an acute aortic dissection (all Stanford classification type A). Discerning clinical manifestations were decreased consciousness in 11/15 (73%), pain in 8/15 (53%) and low systolic blood pressure (mean 106 mmHg, SD30). Acute aortic dissection was an incidental finding during computed tomography-angiography in 4/15 (27%). Two out of 15 patients (13%) received intravenous thrombolysis, 9/15 (60%) underwent aortic surgery and 10/15 (67%) died. Of those who survived, 3/5 (60%) had a good functional outcome (modified Rankin Scale 0–2). Discussion and Conclusion In our comprehensive stroke centre, about 1/200 code stroke patients and 1/125 patients with acute ischaemia had an acute aortic dissection. Multicentre studies are necessary to acquire a more reliable estimate of the incidence of acute aortic dissection in the code stroke population. Given the ramifications of missing this diagnosis, imaging of the entire aortic arch is important in these patients.
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Affiliation(s)
- Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Laura Posthuma
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adrien E Groot
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hanna Talacua
- Department of Cardiothoracic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Abdullah Kaya
- Department of Cardiothoracic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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13
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Ernst M, Boers AMM, Forkert ND, Berkhemer OA, Roos YB, Dippel DWJ, van der Lugt A, van Oostenbrugge RJ, van Zwam WH, Vettorazzi E, Fiehler J, Marquering HA, Majoie CBLM, Gellissen S. Impact of Ischemic Lesion Location on the mRS Score in Patients with Ischemic Stroke: A Voxel-Based Approach. AJNR Am J Neuroradiol 2018; 39:1989-1994. [PMID: 30287456 DOI: 10.3174/ajnr.a5821] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/07/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies indicated that ischemic lesion volume might be a useful surrogate marker for functional outcome in ischemic stroke but should be considered in the context of lesion location. In contrast to previous studies using the ROI approach, which has several drawbacks, the present study aimed to measure the impact of ischemic lesion location on functional outcome using a more precise voxelwise approach. MATERIALS AND METHODS Datasets of patients with acute ischemic strokes from the Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) were used. Primary outcome was functional outcome as assessed by the modified Rankin Scale 3 months after stroke. Ischemic lesion volume was determined on CT scans 3-9 days after stroke. Voxel-based lesion-symptom mapping techniques, including covariates that are known to be associated with functional outcome, were used to determine the impact of ischemic lesion location for outcome. RESULTS Of the 500 patients in the MR CLEAN trial, 216 were included for analysis. The mean age was 63 years. Lesion-symptom mapping with inclusion of covariates revealed that especially left-hemispheric lesions in the deep periventricular white matter and adjacent internal capsule showed a great influence on functional outcome. CONCLUSIONS Our study confirms that infarct location has an important impact on functional outcome of patients with stroke and should be considered in prediction models. After we adjusted for covariates, the left-hemispheric corticosubcortical fiber tracts seemed to be of higher functional importance compared with cortical lesions.
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Affiliation(s)
- M Ernst
- From the Departments of Diagnostic and Interventional Neuroradiology (M.E., J.F., S.G.)
| | - A M M Boers
- Departments of Radiology and Nuclear Medicine (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics (A.M.M.B., H.A.M.).,Department of Robotics and Mechatronics (A.M.M.B.), University of Twente, Enschede, the Netherlands
| | - N D Forkert
- Department of Radiology and Hotchkiss Brain Institute (N.D.F.), University of Calgary, Calgary, Alberta, Canada
| | - O A Berkhemer
- Departments of Radiology and Nuclear Medicine (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.).,Departments of Neurology (O.A.B., D.W.J.D.).,Department of Radiology (O.A.B.), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Y B Roos
- Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands
| | | | - A van der Lugt
- Radiology (A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - R J van Oostenbrugge
- Department of Neurology (R.J.v.O.), Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht, the Netherlands
| | - W H van Zwam
- Department of Radiology and Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center, Maastricht, the Netherlands
| | - E Vettorazzi
- Medical Biometry and Epidemiology (E.V.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Fiehler
- From the Departments of Diagnostic and Interventional Neuroradiology (M.E., J.F., S.G.)
| | - H A Marquering
- Departments of Radiology and Nuclear Medicine (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics (A.M.M.B., H.A.M.)
| | - C B L M Majoie
- Departments of Radiology and Nuclear Medicine (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.)
| | - S Gellissen
- From the Departments of Diagnostic and Interventional Neuroradiology (M.E., J.F., S.G.)
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14
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Boers AM, Jansen IG, Berkhemer OA, Yoo AJ, Lingsma HF, Slump CH, Roos YB, van Oostenbrugge RJ, Dippel DW, van der Lugt A, van Zwam WH, Marquering HA, Majoie CB. Collateral status and tissue outcome after intra-arterial therapy for patients with acute ischemic stroke. J Cereb Blood Flow Metab 2017; 37:3589-3598. [PMID: 27864462 PMCID: PMC5669341 DOI: 10.1177/0271678x16678874] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [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] [Indexed: 11/16/2022]
Abstract
Intra-arterial therapy (IAT) for ischemic stroke aims to save brain tissue. Collaterals are thought to contribute to prolonged penumbra sustenance. In this study, we investigate the effect of collateral status on brain tissue salvage with IAT. In 500 patients randomized between IAT and standard care, collateral status was graded from 0 (absent) to 3 (good). Final infarct volumes (FIV) were calculated on post-treatment CT. FIVs were compared between treatment groups per collateral grade. Multivariable linear regression with interaction terms was performed to study whether collaterals modified IAT effect on FIV. Four-hundred-forty-nine patients were included in the analysis. Median FIV for the IAT group was significantly lower with 54.5 mL (95% IQR: 21.8-145.0) than for the controls with 81.8 mL (95% IQR: 40.0-154.0) ( p = 0.020). Treatment effect differed across collateral grades, although there was no significant interaction (unadjusted p = 0.054; adjusted p = 0.105). For grade 3, IAT resulted in a FIV reduction of 30.1 mL ( p = 0.024). For grade 2 and 1, this difference was, respectively, 28.4 mL ( p = 0.028) and 28.4 mL ( p = 0.29). For grade 0, this was 88.6 mL ( p = 0.28) in favour of controls. IAT saves substantially more brain tissue as compared to standard care. We observed a trend of increasing effect of IAT with higher collateral grades.
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Affiliation(s)
- Anna Mm Boers
- 1 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.,2 Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands.,3 Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, the Netherlands
| | - Ivo Gh Jansen
- 1 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.,3 Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, the Netherlands
| | - Olvert A Berkhemer
- 1 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.,4 Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,5 Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Albert J Yoo
- 6 Division of Neurointervention, Texas Stroke Institute, Dallas, TX, USA
| | - Hester F Lingsma
- 7 Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Cornelis H Slump
- 2 Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands.,8 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Yvo Bwem Roos
- 9 Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | - Robert J van Oostenbrugge
- 10 Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Diederik Wj Dippel
- 4 Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- 11 Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wim H van Zwam
- 5 Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands.,10 Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Henk A Marquering
- 1 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.,3 Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, the Netherlands
| | - Charles Blm Majoie
- 1 Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
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15
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Schreuders J, van den Berg LA, Fransen PS, Berkhemer OA, Beumer D, Lingsma HF, van Oostenbrugge RJ, van Zwam WH, Majoie CB, van der Lugt A, de Kort PL, Roos YB, Dippel DW. Quality of life after intra-arterial treatment for acute ischemic stroke in the MR CLEAN trial-Update. Int J Stroke 2017; 12:708-712. [PMID: 28436305 DOI: 10.1177/1747493017706244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Health-related quality of life measured with the EuroQol Group 5-Dimension Self-Report Questionnaire was one of the secondary outcomes in the Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN). We reported no statistically significant difference in EuroQol Group 5-Dimension Self-Report Questionnaire score between the intervention and control groups, but deaths were not included. Aims Reanalyze the effect of intra-arterial treatment for large vessel occlusion in acute ischemic stroke patients on health-related quality of life in more detail. We now include patients who died during follow-up. Methods The EuroQol Group 5-Dimension Self-Report Questionnaire questionnaires were obtained 90 days after treatment. We used the Dutch tariff to derive a utility index from the EuroQol Group 5-Dimension Self-Report Questionnaire score. Treatment effect was estimated with the Mann-Whitney U test and linear regression. The effect of treatment on the distribution of EuroQol Group 5-Dimension Self-Report Questionnaire dimension scores was assessed with ordinal logistic regression. Results We obtained EuroQol Group 5-Dimension Self-Report Questionnaire scores from 457 (91.7%) of the 500 patients, including 108 who died before follow-up. Median EuroQol Group 5-Dimension Self-Report Questionnaire score in the intervention group was 0.57, and 0.39 in the control group (p = 0.03). Treatment effect estimated with linear regression was 0.07 (95%CI: -0.001 to 0.143). Treatment specifically affected EuroQol Group 5-Dimension Self-Report Questionnaire dimensions "mobility" (OR: 0.43, 95%CI: 0.29-0.66), "self-care" (OR: 0.60, 95%CI: 0.41-0.89), and "usual activities" (OR: 0.53, 95%CI: 0.36-0.79). Conclusion Treatment had a limited effect on quality of life, as measured with the EuroQol Group 5-Dimension Self-Report Questionnaire. Nevertheless, patients with acute ischemic stroke caused by an intracranial occlusion in the anterior circulation, who had intra-arterial treatment, experience better health-related quality of life than patients without intra-arterial treatment. Trial Registration URL: http://www.isrctn.com/ISRCTN10888758 Unique identifier: ISRCTN10888758.
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Affiliation(s)
- Jennifer Schreuders
- 1 Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.,2 Department of Neurology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Puck Ss Fransen
- 1 Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.,4 Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Olvert A Berkhemer
- 1 Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.,5 Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Debbie Beumer
- 1 Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.,6 Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hester F Lingsma
- 7 Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert J van Oostenbrugge
- 6 Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- 8 Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Charles Blm Majoie
- 5 Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Aad van der Lugt
- 4 Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Paul Lm de Kort
- 2 Department of Neurology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Yvo Bwem Roos
- 3 Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Diederik Wj Dippel
- 1 Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
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16
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Ubbink DT, Vermeulen H, Knops AM, Legemate DA, Oude Rengerink K, Heineman MJ, Roos YB, Fijnvandraat CJ, Heymans HS, Simons R, Levi M. Implementation of evidence-based practice: outside the box, throughout the hospital. Neth J Med 2011; 69:87-94. [PMID: 21411849] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Evidence-based practice (EBP) is a generally accepted means to improve healthcare quality. However, not all healthcare professionals and managers apply EBP in daily practice. We investigated EBP attitudes, knowledge and the perceived barriers and facilitators to practising EBP , to define tailor-made interventions for improving evidence-based behaviour. METHODS In this cross-sectional survey, doctors and nurses from five major specialities of a university hospital were invited to complete the McColl and Barriers questionnaires. RESULTS Response rates were 70% (305÷435) for doctors and 74% (396÷537) for nurses. They were welcoming towards EBP, but considered time constraints, knowledge gaps and poor availability of evidence as major barriers to implement EBP . They also mentioned contradicting results (75%) and flawed methodology (69%), while nurses frequently mentioned unawareness of (75%), or difficulty in reading and interpreting research papers (70%). Regarding EBP knowledge, 6/8 common EBP terms could be explained by 54% of doctors but by only 15% of nurses. Facilitating factors among doctors concerned the availability and accessibility of high-level evidence and communication of evidence during various clinical meetings and handovers for clinical decision making. Among nurses, promoting factors involved more teaching and instances to incorporate EBP in clinical practice. Both groups desired more managerial support in terms of motivation and opportunities. CONCLUSIONS Doctors and nurses have embraced the EBP paradigm as an important means to improve quality of clinical patient care, but its application is still cumbersome. This paper offers a tailored programme for implementation and managerial role-models.sustainment of EBP, corroborated by professional and managerial role-models.
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Affiliation(s)
- D T Ubbink
- Department of Quality Assurance & Process Innovation, University of Amsterdam, the Netherlands.
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17
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Kruyt ND, Musters A, Biessels GJ, Devries JH, Coert BA, Vergouwen MDI, Horn J, Roos YB. Beta-cell dysfunction and insulin resistance after subarachnoid haemorrhage. Neuroendocrinology 2011; 93:126-32. [PMID: 21293115 DOI: 10.1159/000324097] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 01/02/2011] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hyperglycaemia is a common finding and an independent risk factor for increased morbidity and mortality in aneurysmal subarachnoid haemorrhage (SAH). Although in these patients hyperglycaemia is commonly ascribed to insulin resistance, there is little understanding of underlying mechanisms. AIMS To prospectively study temporal disturbances of glucose metabolism after aneurysmal SAH in patients without known abnormalities of glucose metabolism and to explore possible correlations with markers of stress. METHODS In consecutive aneurysmal SAH patients not subjected to insulin therapy, in-hospital and follow-up oral glucose tolerance tests (OGTTs) and assessments of insulin resistance, pancreatic β-cell function, free fatty acids (FFA) and cortisol were performed and compared with reference values. RESULTS We included 13 patients. In the first 2 weeks of admission, median fasting glucose and FFA levels were elevated while insulin levels were not. OGTTs were indicative of glucose intolerance in all patients at days 3 and 7, while on follow-up 1 patient had glucose intolerance and all patients had normal fasting glucose levels. Pancreatic β-cell function was impaired throughout the first week and insulin resistance from day 4 to 10. Levels of cortisol correlated with higher fasting glucose and increased FFA. FFA in turn correlated with pancreatic β-cell dysfunction. CONCLUSIONS Aneurysmal SAH patients have transient abnormalities of glucose metabolism. During the first week, it appears to result predominantly from transient pancreatic β-cell dysfunction, in combination with insulin resistance.
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Affiliation(s)
- N D Kruyt
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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18
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Zinkstok SM, Vermeulen M, Stam J, de Haan RJ, Roos YB. A randomised controlled trial of antiplatelet therapy in combination with Rt-PA thrombolysis in ischemic stroke: rationale and design of the ARTIS-Trial. Trials 2010; 11:51. [PMID: 20459856 PMCID: PMC2886039 DOI: 10.1186/1745-6215-11-51] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 05/12/2010] [Indexed: 12/20/2022] Open
Abstract
Background Thrombolysis with intravenous rt-PA is currently the only approved acute therapy for ischemic stroke. Re-occlusion after initial recanalization occurs in up to 34% in patients treated with rt-PA, probably caused by platelet activation. In acute myocardial infarction, the combination of thrombolysis and antiplatelet therapy leads to a greater reduction of mortality compared to thrombolysis alone. In patients with acute ischemic stroke, several studies showed that patients already on antiplatelet treatment prior to thrombolysis had an equal or even better outcome compared to patients without prior antiplatelet treatment, despite an increased risk of intracerebral bleeding. Based on the fear of intracerebral haemorrhage, current international guidelines recommend postponing antiplatelet therapy until 24 hours after thrombolysis. Remarkably, prior use of antiplatelet therapy is not a contra-indication for thrombolysis. We hypothesize that antiplatelet therapy in combination with rt-PA thrombolysis will improve outcome by enhancing fibrinolysis and preventing re-occlusion. Methods/Design ARTIS is a randomised multi-center controlled trial with blind endpoint assessment. Our objective is to investigate whether immediate addition of aspirin to rt-PA thrombolysis improves functional outcome in ischemic stroke. Patients with acute ischemic stroke eligible for rt-PA thrombolysis are randomised to receive 300 mg aspirin within 1.5 hours after start of thrombolysis or standard care, consisting of antiplatelet therapy after 24 hours. Primary outcome is poor functional health at 3 months follow-up (modified Rankin Scale 3 - 6). Discussion This is the first clinical trial investigating the combination of rt-PA and acute aspirin by means of a simple and cheap adjustment of current antiplatelet regimen. We expect the net benefit of improved functional outcome will overcome the possible slightly increased risk of intracerebral haemorrhage. Trial registration The Netherlands National Trial Register NTR822. The condensed rationale of the ARTIS-Trial has already been published in Cerebrovascular Diseases.
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Affiliation(s)
- S M Zinkstok
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands.
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19
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Vriesendorp TM, Roos YB, Kruyt ND, Biessels GJ, Kappelle LJ, Vermeulen M, Holleman F, DeVries JH, Hoekstra JBL. Efficacy and safety of two 5 day insulin dosing regimens to achieve strict glycaemic control in patients with acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2009; 80:1040-3. [PMID: 19684236 DOI: 10.1136/jnnp.2008.144873] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND In patients with acute ischaemic stroke and hyperglycaemia, prolonged strict glycaemic control may improve clinical outcome. The question is how to achieve this prolonged strict glycaemic control. In this study, the efficacy and safety of two regimens with different basal to meal related insulin ratio are described. METHODS 33 patients with ischaemic stroke and hyperglycaemia at admission were randomised in an open design to receive: (1) conventional glucose lowering therapy, (2) strict glucose control with predominantly basal insulin using intravenous insulin or (3) strict glucose control with predominantly meal related insulin using subcutaneous insulin in the first 5 days after stroke. The target range of glucose control for the last two groups was 4.4-6.1 mmol/l. 16 consecutive patients without hyperglycaemia at admission were included to serve as normoglycaemic controls. RESULTS The median area under the curve (AUC) in the meal related insulin group was 386 mmol/l x 58 h (range 286-662) for days 2-5, and did not differ from the hyperglycaemic control group (median AUC 444 mmol/l x 58 h; range 388-620). There was also no difference in median AUC of the basal insulin group (453 mmol/l x 58 h, range 347-629) and the hyperglycaemic control group on days 2-5. In the first 12 hours, glucose profiles were lower in the groups treated with strict glucose control; median AUC was 90 mmol/l x 12 h (range 77-189) for the hyperglycaemic control group versus 81 mmol/l x 12 h (range 60-118) for the meal related insulin group (p = 0.03) and 74 mmol/l x 12 h (range 52-97) for the basal insulin group (p = 0.008). CONCLUSION In intermittently fed ischaemic stroke patients, strict glycaemic control between day 2 and day 5 with two different basal bolus regimens did not result in lower glucose profiles due to postprandial hyperglycaemia. Continuous enteral feeding may therefore be needed to achieve prolonged strict glycaemic control in acute stroke patients.
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Affiliation(s)
- T M Vriesendorp
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Weisscher N, Vermeulen M, Roos YB, de Haan RJ. What should be defined as good outcome in stroke trials; a modified Rankin score of 0-1 or 0-2? J Neurol 2008; 255:867-74. [PMID: 18338195 DOI: 10.1007/s00415-008-0796-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 10/22/2007] [Accepted: 10/29/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Good outcome in stroke trials has been defined as a modified Rankin scale (mRs) score of 0-1 or 0-2. The aim of this study was to investigate the clinical meaning of these two dichotomies. METHODS We studied 152 patients six months post stroke using the mRs and a new disability measure the AMC Linear Disability Scale (ALDS) item bank. Descriptive statistics were used to show the ALDS scores by the levels of the mRs. To investigate the clinical meaning of the different definitions of good outcome, the mean probability to perform activities of daily life (ADL) of all mRs grades and these two dichotomies was calculated. RESULTS The ability to perform difficult ALDS items declined gradually with increasing mRs grade. When favourable outcome is defined as mRs 0-1, 15 % of the cohort has a good outcome; of these patients 84 % were likely to perform outdoor activities. If good outcome is defined as mRs 0-2, the percentage of patients with good outcome increased to 37 %, whereas 66 % of these patients were likely to perform outdoor activities. CONCLUSION If good outcome is defined as the ability to perform outdoor activities mRs 0-1 should be chosen. If complex ADL are considered as good outcome mRs 0-2 is the outcome measure of choice. Independent of which outcome measure is chosen, the treatment effect in clinical trials must be large before good outcome is achieved. Therefore, it is likely that clinically important treatment effects can be missed in clinical trials with both these mRs endpoints.
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Affiliation(s)
- N Weisscher
- Dept. of Neurology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Abstract
Calcium antagonists have been shown to be superior over other antihypertensive drugs to prevent stroke. Because this cannot be fully attributed to blood pressure lowering effects, other mechanisms seem to play a role. Previously we found in patients with subarachnoid hemorrhage that nimodipine enhances fibrinolytic activity. The purpose of this systematic review was to investigate the fibrinolytic effect of calcium antagonists in general, especially in patients with hypertension. We systematically studied the entire PUBMED and EMBASE database with the search terms 'calcium antagonist' combined with 'fibrinolysis', '(euglobulin) clot lysis time' (ECLT), 'tissue plasminogen activator' (tPA), or 'plasminogen activator inhibitor' (PAI). Twenty-six prospective studies were identified and 22 manuscripts were included (802 investigated individuals). The results show that calcium antagonists significantly increase fibrinolysis as shown by a reduction of the ECLT standardized mean differences (SMD) -0.58 (95% confidence interval (CI) -1.05 to -0.11)) and an increase of tPA activity (SMD 0.73 (95% CI 0.25 to 1.21)). This increase of fibrinolysis is apparently caused by an increase of the tPA antigen level (SMD 0.16 (95% CI -0.05 to 0.37)) and a decrease of the plasminogen activator inhibitor-1 antigen antigen (SMD -0.36 (95% CI -0.74 to 0.02)). A sensitivity analysis showed that dihydropyridines, but not phenylalkylamines, exert a fibrinolytic effect. This fibrinolytic effect is not only seen in patients with subarachnoid hemorrhage but also in hypertensive patients. In conclusions, calcium antagonists increase fibrinolytic activity. This may add to the beneficial pharmacological effect of calcium antagonists to prevent ischemic events in patients with hypertension and subarachnoid hemorrhage.
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Affiliation(s)
- Mervyn D I Vergouwen
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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22
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Abstract
BACKGROUND AND PURPOSE The purpose of this study was first, to investigate which factor in the fibrinolytic cascade is responsible for the recently observed increase of fibrinolytic activity in patients with aneurysmal subarachnoid hemorrhage (SAH), and second, the cause of this increase. METHODS Fibrinolytic activity and the main regulators of endogenous fibrinolytic activity, tissue plasminogen activator, and plasminogen activator inhibitor 1 (PAI-1) were measured in patients treated with and without nimodipine. RESULTS In patients with aneurysmal SAH, fibrinolytic activity significantly increases from 2.7 IU/mL on admission to 4.2 IU/mL in week 3 (P<0.01, paired-sample t test), caused by a 1.6-fold decrease in plasma levels of PAI-1. The results also show that increased fibrinolytic activity is seen only in patients treated with nimodipine and that plasminogen activity and PAI-1 returned to baseline levels after treatment with nimodipine had been discontinued. CONCLUSIONS The mechanism of increased fibrinolytic activity in patients with aneurysmal SAH is a decrease in the level of PAI-1, which is most likely caused by treatment with nimodipine.
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Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Center, University of Amsterdam, The Netherlands
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Roos YB, de Haan RJ, Beenen LF, Groen RJ, Albrecht KW, Vermeulen M. Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in the Netherlands. J Neurol Neurosurg Psychiatry 2000; 68:337-41. [PMID: 10675216 PMCID: PMC1736841 DOI: 10.1136/jnnp.68.3.337] [Citation(s) in RCA: 213] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to investigate prospectively in an unselected series of patients with an aneurysmal subarachnoid haemorrhage what at present the complications are, what the outcome is, how many of these patients have "modern treatment"-that is, early obliteration of the aneurysm and treatment with calcium antagonists-what factors cause a delay in surgical or endovascular treatment, and what the estimated effect on outcome will be of improved treatment. METHODS A prospective, observational cohort study of all patients with aneurysmal subarachnoid haemorrhage in the hospitals of a specified region in The Netherlands. The condition on admission, diagnostic procedures, and treatments were recorded. If a patient had a clinical deterioration, the change in Glasgow coma score (GCS), the presence of focal neurological signs, the results of additional investigations, and the final diagnosed cause of the deterioration were recorded. Clinical outcome was assessed with the Glasgow outcome scale (GOS) at 3 month follow up. In patients with poor outcome at follow up, the cause was diagnosed. RESULTS Of the 110 patients, 47 (43%) had a poor outcome. Cerebral ischaemia, 31 patients (28%), was the most often occurring complication. Major causes of poor outcome were the effects of the initial haemorrhage and rebleeding in 34% and 30% of the patients with poor outcome respectively. Of all patients 102 (93%) were treated with calcium antagonists and 45 (41%) patients had early treatment to obliterate the aneurysm. The major causes of delay of treatment were a poor condition on admission or deterioration shortly after admission, in 31% and 23% respectively. CONCLUSIONS In two thirds of the patients with poor outcome the causes of poor outcome are the effects of the initial bleeding and rebleeding. Improved treatment of delayed or postoperative ischaemia will have only minor effects on the outcome of patients with subarachnoid haemorrhage.
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Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Roos YB, Vermeulen M, Rinkel GJ, Algra A, Van Gijn J, Algra A. Systematic review of antifibrinolytic treatment in aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1998; 65:942-3. [PMID: 9854979 PMCID: PMC2170374 DOI: 10.1136/jnnp.65.6.942] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Centre, University of Amsterdam, The Netherlands.
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Roos YB, Beenen LF, Groen RJ, Albrecht KW, Vermeulen M. Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery. J Neurol Neurosurg Psychiatry 1997; 63:490-3. [PMID: 9343129 PMCID: PMC2169792 DOI: 10.1136/jnnp.63.4.490] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome. METHODS A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded. RESULTS The proportion of patients that was operated on early--that is, within three days after SAH--was 55%. Thirty seven of all 102 admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome. CONCLUSIONS In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome.
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Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Centre, University of Amsterdam, The Netherlands
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Abstract
Patients with large amounts of intraventricular blood have a poor prognosis. The question is whether the quantity of ventricular blood or other factors related to the origin of the intraventricular bleeding cause poor outcome. The association between ventricular blood volume and outcome was analysed in patients with a primary intraventricular haemorrhage (PIVH) and in patients with an aneurysmal subarachnoid haemorrhage (SAH). The medical records of 24 patients with PIVH were reviewed and these patients were compared with 59 patients selected from a prospectively studied series of patients with aneurysmal SAH who had intraventricular blood without an intraparenchymal haematoma. Glasgow coma score on admission and outcome at three months expressed on the Glasgow outcome scale were available for all patients. Volumetric analysis on CT was carried out if there was at least a moderate amount of blood measured with a semi-quantitative scale (SAH n = 30, PIVH n = 22). In patients with SAH more than 20 ml intraventricular blood was lethal, as previously shown for patients with intraparenchymal haemorrhage. Patients with a PIVH can, however, survive such large volumes of intraventricular blood without impaired consciousness immediately after the bleeding, without developing hydrocephalus, and without any disability after three months. It is concluded that the cause of an intraventricular haemorrhage is more important for outcome than the amount of intraventricular blood, and large intraventricular haemorrhages are not always associated with hydrocephalus.
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Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Center, University of Amsterdam, The Netherlands
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