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Broocks G, McDonough RV, Bechstein M, Klapproth S, Faizy TD, Schön G, Kniep HC, Bester M, Hanning U, Kemmling A, Zeleñák K, Fiehler J, Meyer L. Thrombectomy in Patients With Ischemic Stroke Without Salvageable Tissue on CT Perfusion. Stroke 2024; 55:1317-1325. [PMID: 38572635 DOI: 10.1161/strokeaha.123.044916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 02/22/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging is regularly used to guide patient selection for mechanical thrombectomy (MT). However, the effect of MT in patients without salvageable tissue on CTP has not been investigated. The purpose of this study was to assess the effect of MT in patients with stroke without perfusion mismatch profiles. METHODS This observational study analyzed patients with ischemic stroke consecutively treated between March 1, 2015, and January 31, 2022, triaged by multimodal-computed tomography undergoing MT. CTP lesion-core mismatch profiles were defined using a mismatch volume/ratio of ≥10 mL/1.2, respectively. The primary end point was the rate of functional independence at 90 days, defined as the modified Rankin Scale score of 0 to 2. Recanalization was evaluated with the modified Thrombolysis in Cerebral Infarction scale. The effect of baseline variables on functional outcome was assessed using multivariable logistic regression analysis. Outcomes of patients with and without CTP-mismatch profiles were compared using 1:1 propensity score matching. RESULTS Of 724 patients who met the inclusion criteria of this retrospective observational study, 110 (15%) patients had no CTP mismatch and were analyzed. The median age was 74 (interquartile range, 62-80) years and 53% were women. Successful recanalization (modified Thrombolysis in Cerebral Infarction score, ≥2b) was achieved in 66% (73) and associated with functional independence at 90 days (adjusted odds ratio, 7.33 [95% CI, 1.22-43.70]; P=0.03). A significant interaction was observed between recanalization and age, as well as the extent of infarction, indicating MT to be most effective in patients <70 years and with a baseline Alberta Stroke Program Early Computed Tomography Score range between 3 and 7. These findings remained stable after propensity score matching, analyzing 152 matched pairs with similar rates of functional independence between patients with and without CTP-mismatch profiles (17% versus 23%; P=0.42). CONCLUSIONS In patients without CTP-mismatch profiles defined according to the EXTEND (Extending the Time for Thrombolysis in Emergency Neurological Deficits) criteria, recanalization was associated with improved functional outcomes. This effect was associated with baseline Alberta Stroke Program Early Computed Tomography Score and age, but not with the time from onset to imaging.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany (G.B.)
| | | | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology (G.S.) University Medical Center Hamburg-Eppendorf, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - André Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Marburg, Marburg, Germany (A.K.)
| | - Kamil Zeleñák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia (K.Z.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
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Sui Y, Chen W, Chen C, Chang Y, Bivard A, Wang P, Geng Y, Parsons M, Lin L. CTP-Defined Large Core Is a Better Predictor of Poor Outcome for Endovascular Treatment Than ASPECTS-Defined Large Core. Stroke 2024; 55:1227-1234. [PMID: 38488357 DOI: 10.1161/strokeaha.123.045091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/31/2024] [Indexed: 04/24/2024]
Abstract
BACKGROUND Recent trials confirmed the effectiveness of endovascular therapy in patients with large ischemic cores. Yet the optimal neuroimaging modalities to define large core remains unclear. We tried to address this question by comparing the functional outcomes in patients receiving thrombectomy selected by either noncontrast computed tomography Alberta Stroke Program Early Computed Tomography Score (ASPECTS) or computed tomography perfusion (CTP). METHODS This study retrospectively selected patients enrolled in the International Stroke Perfusion Registry between August 2011 and April 2022. Patients with acute stroke with large vessel occlusion in anterior circulation treated with endovascular therapy were included. All received both CTP and noncontrast computed tomography. The primary outcome was defined as poor functional outcome represented by a modified Rankin Scale score of 5 to 6 at 3 months. Large cores were defined in terms of either (1) noncontrast computed tomography ASPECTS ≤5 or (2) core volume ≥70 mL on CTP. RESULTS A total of 1115 patients were included in the analysis, of which 90 patients had ASPECTS ≤5 (8.1%) and 97 patients CTP core ≥70 mL (8.7%). A fair agreement between ASPECTS and CTP with a κ value of 0.31 (0.21-0.40) was found. Compared with patients with neither CTP nor ASPECTS large cores, those with only ASPECTS-defined large cores (ie, ASPECTS ≤5; n=56) did not have a higher adjusted odds of poor outcome (29%; odds ratio, 1.84 [0.91-3.73]; P=0.089). However, patients with CTP large core but not ASPECTS-defined large core (n=63) had a higher adjusted odds of poor outcome (60%; odds ratio, 3.91 [2.01-7.60]; P<0.001). In time-stratified subgroup analysis (>6 versus ≤6 hours), ASPECTS showed no discriminative difference between ≤5 and >5 in poor outcome for patients receiving endovascular therapy within 6 hours. CONCLUSIONS CTP core ≥70 mL-defined large cores are more predictive of poor outcome than ASPECTS ≤5-defined core in endovascular therapy patients, particularly within 6 hours after stroke onset.
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Affiliation(s)
- Yi Sui
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang Clinical Research Center for Neurological Diseases, China (Y.S.)
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China (Y.S.)
| | - Wenhuo Chen
- Zhangzhou Affiliated Hospital of Fujian Medical University, China (W.C.)
| | - Chushuang Chen
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
| | - Yanting Chang
- School of Public Health, China Medical University, Shenyang, China (Y.C.)
| | - Andrew Bivard
- Melbourne Brain Centre, University of Melbourne, Australia (A.B.)
| | - Peng Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China (P.W., Y.G.)
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China (P.W., Y.G.)
| | - Mark Parsons
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
- South Western Clinical School, University of New South Wales, Sydney, Australia (M.P., L.L.)
| | - Longting Lin
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
- South Western Clinical School, University of New South Wales, Sydney, Australia (M.P., L.L.)
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Sarraj A, Campbell BCV. Does Reperfusion Benefit Patients Without Perfusion Mismatch? Stroke 2024; 55:1326-1328. [PMID: 38572633 DOI: 10.1161/strokeaha.124.046989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, OH (A.S.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, VIC, Australia (B.C.V.C.)
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Seners P, Ter Schiphorst A, Wouters A, Yuen N, Mlynash M, Arquizan C, Heit JJ, Kemp S, Christensen S, Sablot D, Wacongne A, Lalu T, Costalat V, Albers GW, Lansberg MG. Clinical change during inter-hospital transfer for thrombectomy: Incidence, associated factors, and relationship with outcome. Int J Stroke 2024:17474930241246952. [PMID: 38576067 DOI: 10.1177/17474930241246952] [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: 04/06/2024]
Abstract
BACKGROUND Patients with acute ischemic stroke with a large vessel occlusion (LVO) admitted to non endovascular-capable centers often require inter-hospital transfer for thrombectomy. We aimed to describe the incidence of substantial clinical change during transfer, the factors associated with clinical change, and its relationship with 3-month outcome. METHODS We analyzed data from two cohorts of acute stroke patients transferred for thrombectomy to a comprehensive center (Stanford, USA, November 2019 to January 2023; Montpellier, France, January 2015 to January 2017), regardless of whether thrombectomy was eventually attempted. Patients were included if they had evidence of an LVO at the referring hospital and had a National Institute of Health Stroke Scale (NIHSS) score documented before and immediately after transfer. Inter-hospital clinical change was categorized as improvement (⩾4 points and ⩾25% decrease between the NIHSS score in the referring hospital and upon comprehensive center arrival), deterioration (⩾4 points and ⩾25% increase), or stability (neither improvement nor deterioration). The stable group was considered as the reference and was compared to the improvement or deterioration groups separately. RESULTS A total of 504 patients were included, of whom 22% experienced inter-hospital improvement, 14% deterioration, and 64% were stable. Pre-transfer variables independently associated with clinical improvement were intravenous thrombolysis use, more distal occlusions, and lower serum glucose; variables associated with deterioration included more proximal occlusions and higher serum glucose. On post-transfer imaging, clinical improvement was associated with arterial recanalization and smaller infarct growth and deterioration with larger infarct growth. As compared to stable patients, those with clinical improvement had better 3-month functional outcome (adjusted common odds ratio (cOR) = 2.43; 95% confidence interval (CI) = 1.59-3.71; p < 0.001), while those with deterioration had worse outcome (adjusted cOR = 0.60; 95% CI = 0.37-0.98; p = 0.044). CONCLUSION Substantial inter-hospital clinical changes are frequently observed in LVO-related ischemic strokes, with significant impact on functional outcome. There is a need to develop treatments that improves the clinical status during transfer. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request.
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Affiliation(s)
- Pierre Seners
- Stanford Stroke Center, Palo Alto, CA, USA
- Department of Neurology, Rothschild Foundation Hospital, Paris, France
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Paris, France
| | | | - Anke Wouters
- Stanford Stroke Center, Palo Alto, CA, USA
- Division of Experimental Neurology, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | | | | | - Jeremy J Heit
- Department of Radiology, Stanford University, Palo Alto, CA, USA
| | | | | | - Denis Sablot
- Neurology Department, CH Perpignan, Perpignan, France
| | | | | | - Vincent Costalat
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
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Pestka DL, Boes S, Ramezani S, Peters M, Usher MG, Koopmeiners JS, Beebe TJ, Melton GB, Streib CD. Implementing Telestroke in the Inpatient Setting: Identifying Factors for Success. Stroke 2024. [PMID: 38639090 DOI: 10.1161/strokeaha.123.046024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Inpatient telestroke programs have emerged as a solution to provide timely stroke care in underserved areas, but their successful implementation and factors influencing their effectiveness remain underexplored. This study aimed to qualitatively evaluate the perspectives of inpatient clinicians located at spoke hospitals participating in a newly established inpatient telestroke program to identify implementation barriers and facilitators. METHODS This was a formative evaluation relying on semistructured qualitative interviews with 16 inpatient providers (physicians and nurse practitioners) at 5 spoke sites of a hub-and-spoke inpatient telestroke program. The Integrated-Promoting Action on Research Implementation in Health Services framework guided data analysis, focusing on the innovation, recipients, context, and facilitation aspects of implementation. Interviews were transcribed and coded using thematic analysis. RESULTS Fifteen themes were identified in the data and mapped to the Integrated-Promoting Action on Research Implementation in Health Services framework. Themes related to the innovation (the telestroke program) included easy access to stroke specialists, the benefits of limiting patient transfers, concerns about duplicating tests, and challenges of timing inpatient telestroke visits and notes to align with discharge workflow. Themes pertaining to recipients (care team members and patients) were communication gaps between teams, concern about the supervision of inpatient telestroke advanced practice providers and challenges with nurse empowerment. With regard to the context (hospital and system factors), providers highlighted familiarity with telehealth technologies as a facilitator to implementing inpatient telestroke, yet highlighted resource limitations in smaller facilities. Facilitation (program implementation) was recognized as crucial for education, standardization, and buy-in. CONCLUSIONS Understanding barriers and facilitators to implementation is crucial to determining where programmatic changes may need to be made to ensure the success and sustainment of inpatient telestroke services.
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Affiliation(s)
- Deborah L Pestka
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Samuel Boes
- Department of Neurology, University of Minnesota, Minneapolis. (S.B., S.R., C.D.S.)
| | - Solmaz Ramezani
- Department of Neurology, University of Minnesota, Minneapolis. (S.B., S.R., C.D.S.)
| | - Maya Peters
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Michael G Usher
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Joseph S Koopmeiners
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis. (J.S.K.)
| | - Timothy J Beebe
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Division of Health Policy Management, School of Public Health, University of Minnesota, Minneapolis. (T.J.B.)
| | - Genevieve B Melton
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Department of Surgery, University of Minnesota, Minneapolis.(G.B.M.)
- Institute for Health Informatics, University of Minnesota, Minneapolis. (G.B.M.)
| | - Christopher D Streib
- Department of Neurology, University of Minnesota, Minneapolis. (S.B., S.R., C.D.S.)
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Rowling H, Italiano D, Churilov L, Palanikumar L, Harvey J, Kleinig T, Parsons M, Mitchell P, Davis S, Kruyt N, Campbell B, Zhao H. Large vessel occlusive stroke with milder baseline severity shows better collaterals and reduced harm from thrombectomy transfer delays. Int J Stroke 2024:17474930241242954. [PMID: 38506406 DOI: 10.1177/17474930241242954] [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: 03/21/2024]
Abstract
BACKGROUND Patients with large vessel occlusion (LVO) stroke presenting with milder baseline clinical severity are common and require endovascular thrombectomy. However, such patients are difficult to recognize using pre-hospital severity-based triage tools and therefore are likely to require a secondary inter-hospital transfer if transported to a non-thrombectomy center. Given the potential for milder severity to represent better underlying cerebrovascular collateral circulation, it is unknown whether transfer delays are still associated with poorer post-stroke outcomes in this patient group. AIMS We primarily aimed to examine whether the harmful effect of inter-hospital transfer delay for thrombectomy was different for LVO patients with mild or severe deficits. Secondarily, we also investigated whether imaging markers of collateral circulation were different between severity groups. METHODS Registry data from two large Australian thrombectomy centers were used to identify all directly presenting and secondarily transferred LVO patients undergoing thrombectomy, divided into those with lower (NIHSS < 10) and higher (NIHSS ⩾ 10) baseline deficits. The primary outcome was the functional independence or return to baseline defined as modified Rankin Scale 0-2 or baseline at 90 days. Patients with complete baseline CT-perfusion data were analyzed for imaging markers of collateral circulation by baseline severity group. RESULTS A total of 1210 LVO patients undergoing thrombectomy were included, of which 273 (22.6%) had lower baseline severity. Despite similar thrombolysis and recanalization rates, transferred patients had lower odds of achieving the primary outcome compared to the primary presentation to a thrombectomy center, where baseline severity was higher (adjusted odds ratio (aOR) 0.759 (95% CI 0.576-0.999)), but not when severity was lower (aOR 1.357 (95% CI 0.764-2.409), p-interaction = 0.122). In the imaging analysis of 436 patients, those with milder severity showed smaller median ischemic core volumes (12.6 (IQR 0.0-17.9) vs 27.5 (IQR 6.5-37.1) mL, p < 0.001)), higher median perfusion mismatch ratio (10.8 (IQR 4.8-54.5) vs 6.6 (IQR 3.5-16.5), p < 0.001), and lower median hypoperfusion intensity ratio (0.25 (IQR 0.18-0.38) vs 0.40 (IQR 0.22-0.57), p < 0.001). DISCUSSION Patients receiving secondary inter-hospital transfer for thrombectomy had poorer outcomes compared to those presenting directly to a thrombectomy center if baseline deficits were severe, but this difference was not observed when baseline deficits were milder. This result may potentially be due to our secondary findings of significantly improved collateral circulation markers in lower-severity LVO patients. As such, failure of pre-hospital screening tools to detect lower-severity LVO patients for pre-hospital bypass to a thrombectomy center may not necessarily deleteriously affect outcome. DATA ACCESS STATEMENT Anonymized data not published within this article will be made available on request from any qualified investigator.
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Affiliation(s)
- Hannah Rowling
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Dominic Italiano
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Logesh Palanikumar
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jackson Harvey
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark Parsons
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, NSW, Australia
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Peter Mitchell
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Stephen Davis
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Nyika Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bruce Campbell
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Henry Zhao
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
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Gordon Perue GL, Southerland AM. Law and Disorder in the Wild West of Stroke Certification: Is It Time to Standardize the Designation Processes? Stroke 2024; 55:1059-1061. [PMID: 38469727 DOI: 10.1161/strokeaha.124.046275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
| | - Andrew M Southerland
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville (A.M.S.)
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Marta-Enguita J, Navarro-Oviedo M, Machado FJDM, Bermejo R, Aymerich N, Herrera M, Zandio B, Pagola J, Juega J, Marta-Moreno J, Rodriguez JA, Páramo JA, Roncal C, Muñoz R, Orbe J. Role of factor XIII in ischemic stroke: a key molecule promoting thrombus stabilization and resistance to lysis. J Thromb Haemost 2024; 22:1080-1093. [PMID: 38160727 DOI: 10.1016/j.jtha.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 12/14/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Active coagulation factor XIII (FXIII) catalyzing crosslinking of fibrin and other hemostatic factors plays a key role in clot stability and lysis. OBJECTIVES To evaluate the effect of FXIII inhibition in a mouse model of ischemic stroke (IS) and the role of activated FXIII (FXIIIa) in clot formation and lysis in patients with IS. METHODS A ferric chloride IS murine model was performed before and after administration of a FXIIIa inhibitor (FXIIIinh). Thromboelastometry in human and mice blood was used to evaluate thrombus stiffness and lysis with FXIIIinh. FXIIIa-dependent fibrin crosslinking and lysis with fibrinolytic drugs (tissue plasminogen activator and tenecteplase) were studied on fibrin plates and on thrombi and clotted plasma of patients with IS. Finally, circulating and thrombus FXIIIa were measured in 85 patients with IS. RESULTS FXIIIinh administration before stroke induction reduced infarct size, α2-antiplasmin (α2AP) crosslinking, and local microthrombosis, improving motor coordination and fibrinolysis without intracranial bleeds (24 hours). Interestingly, FXIII blockade after stroke also reduced brain damage and neurologic deficit. Thromboelastometry in human/mice blood with FXIIIinh showed delayed clot formation, reduced clot firmness, and shortened tissue plasminogen activator lysis time. FXIIIa fibrin crosslinking increased fibrin density and lysis resistance, which increased further after α2AP addition. FXIIIinh enhanced ex vivo lysis in stroke thrombi and fibrin plates. In patients with IS, thrombus FXIII and α2AP were associated with inflammatory and hemostatic components, and plasma FXIIIa correlated with thrombus α2AP and fibrin. CONCLUSION Our results suggest a key role of FXIIIa in thrombus stabilization, α2AP crosslinking, and lysis resistance, with a protective effect of FXIIIinh in an IS experimental model.
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Affiliation(s)
- Juan Marta-Enguita
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain. https://twitter.com/jmartaen
| | - Manuel Navarro-Oviedo
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain
| | - Florencio J D M Machado
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain
| | - Rebeca Bermejo
- Neurointervencionist Radiology, Hospital Universitario Navarra, Pamplona, Spain
| | - Nuria Aymerich
- Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Maria Herrera
- Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Beatriz Zandio
- Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Jorge Pagola
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Stroke Unit, Vall d'Hebron Instituto de Investigación (VHIR), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Jesús Juega
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Stroke Unit, Vall d'Hebron Instituto de Investigación (VHIR), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Javier Marta-Moreno
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Neurology Department, Hospital Universitario Miguel Servet, IIS-Aragon, Zaragoza, Spain
| | - Jose-Antonio Rodriguez
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), ISCIII, Madrid, Spain
| | - Jose-Antonio Páramo
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), ISCIII, Madrid, Spain; Hematology Department, Clinica Universidad Navarra, Pamplona, Spain
| | - Carmen Roncal
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), ISCIII, Madrid, Spain
| | - Roberto Muñoz
- Neurology Department, Hospital Universitario Navarra, Pamplona, Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Josune Orbe
- Atherothrombosis Laboratory, Cardiovascular Diseases Program, Centro de Investigacion Medica Aplicada (CIMA), Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona Spain; Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS)-Ictus Instituto de Salud Carlos III (ISCIII), Madrid, Spain.
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9
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Sakuta K, Yaguchi H, Nakada R, Miyagawa S, Hasegawa I, Okuno K, Teshigawara A, Fuga M, Shimizu K, Iguchi Y. Yield of Whole Body Computed Tomography in Hyper-Acute Stroke Patients With Large Vessel Occlusion. Vasc Endovascular Surg 2024; 58:287-293. [PMID: 37858317 DOI: 10.1177/15385744231209877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE In the majority of cases, large vessel occlusion (LVO) in ischemic stroke patients has an embolic origin. Systemic embolism can occur simultaneously with brain thrombosis. This retrospective study evaluated the frequency and locations of systemic embolism in LVO stroke patients receiving revascularization therapy. MATERIALS AND METHODS In our facility, we use contrast-enhanced computed tomography (CE-CT) to assess suspected stroke patients and routinely perform CE-CT from the chest to the abdomen after brain CT angiography to rule out contraindications like aortic dissection and trauma for thrombolysis. Systemic embolism is also assessed using these images, while myocardial infarction is evaluated based on electrocardiograms and laboratory findings. Other relevant clinical features of each patient are also analyzed. RESULTS In total, 612 consecutively admitted stroke patients and 32 LVO patients who underwent revascularization therapy were included in the present study. Systemic embolism was identified in four patients (13%). The spleen was the most commonly affected organ, followed by the heart, kidneys, limbs, and lungs. All four patients with systemic embolism exhibited LVO resulting from embolism as the underlying mechanism. CONCLUSION Systemic embolism was observed in 13% of our LVO patients, all of whom had LVO of embolic origin.
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Affiliation(s)
- Kenichi Sakuta
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Hiroshi Yaguchi
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Ryoji Nakada
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Shinji Miyagawa
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Izumu Hasegawa
- Department of Emergency Medicine, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Kenji Okuno
- Department of Emergency Medicine, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Akihiko Teshigawara
- Department of Neurosurgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Michiyasu Fuga
- Department of Neurosurgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Kanichiro Shimizu
- Department of Radiology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
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10
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Xie T, Tang WW. Could emergency admission plasma D-dimer level predict first pass effect of stent retriever thrombectomy in acute ischemic stroke? Acta Radiol 2024; 65:367-373. [PMID: 38111236 DOI: 10.1177/02841851231218375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND Evidence on plasma biomarkers to identify first pass effect (FPE) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) treated with thrombectomy is limited. PURPOSE To evaluate whether plasma D-dimer could predict FPE. MATERIAL AND METHODS Consecutive patients with LVO who underwent first-line stent retriever thrombectomy at our center between January 2018 and August 2021 were enrolled. Patients were classified into the FPE (modified Thrombolysis in Cerebral Infarction [mTICI] ≥2c) group or non-FPE (mTICI 0-2b) group based on angiographic outcomes. Logistic regression analysis was performed to determine the predictors of FPE. The overall ability of D-dimer levels in predicting FPE was evaluated using receiver operating characteristic (ROC) curves. RESULTS In total, 313 patients were included; 88 (28.1%) patients achieved FPE. Compared to those with non-FPE, patients with FPE had more diabetes mellitus history, lower D-dimer levels, higher clot burden score, a higher proportion of M1 middle cerebral artery, and a higher proportion of main stem occlusion pattern (P <0.05). After adjusting for potential variables, D-dimer levels (OR=0.81, 95% CI=0.52-0.96), clot burden score (OR=1.76, 95% CI=1.38-2.87), and main stem occlusion pattern (OR=1.85, 95% CI=1.19-2.62) remained independently associated with FPE. Based on the ROC analysis, the D-dimer as a predictor for predicting FPE presented with a specificity of 79%, a negative predictive value of 87%, and an area under the curve of 0.761. CONCLUSION Low emergency admission plasma D-dimer level is an independent predictor of FPE in patients with AIS treated with stent retriever thrombectomy.
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Affiliation(s)
- Ting Xie
- Department of Radiology, Nanjing Women and Children's Healthcare Hospital, Nanjing, Jiangsu, PR China
| | - Wen-Wei Tang
- Department of Radiology, Nanjing Women and Children's Healthcare Hospital, Nanjing, Jiangsu, PR China
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11
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Winkelmeier L, Heitkamp C, Faizy TD, Broocks G, Kniep H, Meyer L, Bester M, Brekenfeld C, Schell M, Hanning U, Thomalla G, Fiehler J, Flottmann F. Prognostic value of recanalization attempts in endovascular therapy for M2 segment middle cerebral artery occlusions. Int J Stroke 2024; 19:422-430. [PMID: 37935652 PMCID: PMC10964385 DOI: 10.1177/17474930231214769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND There is growing evidence suggesting efficacy of endovascular therapy for M2 occlusions of the middle cerebral artery. More than one recanalization attempt is often required to achieve successful reperfusion in M2 occlusions, associated with general concerns about the safety of multiple maneuvers in these medium vessel occlusions. AIM The aim of this study was to investigate the association between the number of recanalization attempts and functional outcomes in M2 occlusions in comparison with large vessel occlusions (LVO). METHODS Retrospective multicenter cohort study of patients who underwent endovascular therapy for primary M2 occlusions. Patients were enrolled in the German Stroke Registry at 1 of 25 comprehensive stroke centers between 2015 and 2021. The study cohort was subdivided into patients with unsuccessful reperfusion (mTICI 0-2a) and successful reperfusion (mTICI 2b-3) at first, second, third, fourth, or ⩾fifth recanalization attempt. Primary outcome was 90-day functional independence defined as modified Rankin Scale score of 0-2. Safety outcome was the occurrence of symptomatic intracranial hemorrhage. Internal carotid artery or M1 occlusions were defined as LVO and served as comparison group. RESULTS A total of 1078 patients with M2 occlusion were included. Successful reperfusion was observed in 87.1% and 90-day functional independence in 51.9%. The rate of functional independence decreased gradually with increasing number of recanalization attempts (p < 0.001). In both M2 occlusions and LVO, successful reperfusion within three attempts was associated with greater odds of functional independence, while success at ⩾fourth attempt was not. Patients with ⩾4 attempts exhibited higher rates of symptomatic intracranial hemorrhage in M2 occlusions (6.5% vs 2.7%, p = 0.02) and LVO (7.2% vs 3.5%, p < 0.001). CONCLUSION This study suggests a clinical benefit of successful reperfusion within three recanalization attempts in endovascular therapy for M2 occlusions, which was similar in LVO. Our findings reduce concerns about the risk-benefit ratio of multiple attempts in M2 medium vessel occlusions. DATA ACCESS STATEMENT The data that support the findings of this study are available on reasonable request after approval of the German Stroke Registry (GSR) steering committee. CLINICAL TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT03356392.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Yokochi Y, Ikeda H, Tanimura M, Osuki T, Uezato M, Kinosada M, Kurosaki Y, Chin M. Aortogenic calcified cerebral embolism diagnosed with an embolus retrieved by thrombectomy: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE2499. [PMID: 38560945 PMCID: PMC10988230 DOI: 10.3171/case2499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/28/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Calcified cerebral embolism has been reported as a cause of acute cerebral infarction, but an aortogenic origin has rarely been identified as the embolic source. The authors describe a case of aortogenic calcified cerebral embolism in a patient with other embolic sources. OBSERVATIONS In a patient with cerebral infarction and atrial fibrillation, a white hard embolus was retrieved by mechanical thrombectomy. Pathological analysis of the embolus revealed that it was mostly calcified, with some foam cells and giant cells. The macroscopic and pathological findings allowed the authors to finally diagnose an aortogenic calcified cerebral embolism. LESSONS Even in patients with cardiogenic embolic sources, it is possible to identify a complex aortic atheroma with calcification as the embolic source, based on the macroscopic and pathological findings of the embolus retrieved by mechanical thrombectomy.
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Watson NW, Weinberg I, Dicks AB, Carroll BJ, Secemsky EA. Clinical Outcomes and Predictors of Advanced Therapy for the Management of Right Heart Thrombus. Circ Cardiovasc Interv 2024; 17:e013637. [PMID: 38410989 PMCID: PMC11021139 DOI: 10.1161/circinterventions.123.013637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND The role of advanced therapies (systemic thrombolysis, catheter-based treatment, and surgical thrombectomy) for the management of right heart thrombus is poorly defined. In this study, we assessed the clinical predictors and outcomes of advanced therapy compared with anticoagulation alone for the acute management of right heart thrombus. METHODS In this observational cohort study, we analyzed consecutive patients who were treated for right heart thrombus. The primary end point was 90-day all-cause mortality. Clinical predictors of utilizing advanced therapy were assessed with multivariable logistic regression. Propensity score matching was utilized to compare adjusted outcomes between patients receiving advanced therapies versus anticoagulation alone. RESULTS A total of 345 patients were included in the study. Advanced therapy was utilized in 13.6% (N=47) of patients, of which 25.5% (N=12/47) was systemic thrombolysis, 23.4% (N=11/47) was endovascular thrombectomy, and 53.2% (N=25/47) was surgical thrombectomy. Younger age (odds ratio, 0.98 [95% CI, 0.96-0.99]) and concurrent pulmonary embolism (odds ratio, 5.36 [95% CI, 2.48-12.1]) predicted utilization of advanced therapy. In propensity score-matched analysis, there was no difference in 90-day mortality (hazard ratio, 0.46 [95% CI, 0.17-1.22]), in-hospital mortality (odds ratio, 0.64 [95% CI, 0.17-2.19]), or length of stay (β, -4.39 [95% CI, -14.0 to 5.22]) between advanced therapy and anticoagulation. CONCLUSIONS Among a diverse cohort of patients with right heart thrombus, outcomes did not differ between those who underwent advanced therapy and anticoagulation alone. Important predictors for utilizing advanced treatment included younger age and the presence of a concurrent pulmonary embolism. Future studies assessing advanced therapy in larger and broader patient populations are necessary.
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Affiliation(s)
- Nathan W. Watson
- Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ido Weinberg
- Harvard Medical School, Boston, MA
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Andrew B. Dicks
- Department of Vascular Surgery, Prisma Health/University of South Carolina School of Medicine – Greenville, Greenville, SC
| | - Brett J. Carroll
- Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eric A. Secemsky
- Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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14
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Santos ACFDF, Coelho LLS, Caldas GDC, Araújo LC, Gagliardi VDB, Carbonera LA. General anesthesia versus conscious sedation in mechanical thrombectomy for patients with acute ischemic stroke: systematic review and meta-analysis. Arq Neuropsiquiatr 2024; 82:1-7. [PMID: 38608712 PMCID: PMC11014755 DOI: 10.1055/s-0044-1785693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/25/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND After recently published randomized clinical trials, the choice of the best anesthetic procedure for mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) is not definite. OBJECTIVE To compare the efficacy and safety of general anesthesia (GA) versus conscious sedation (CS) in patients with AIS who underwent MT, explicitly focusing on procedural and clinical outcomes and the incidence of adverse events. METHODS PubMed, Embase, and Cochrane were systematically searched for randomized controlled trials (RCTs) comparing GA versus CS in patients who underwent MT due to LVO-AIS. Odds ratios (ORs) were calculated for binary outcomes, with 95% confidence intervals (CIs). Random effects models were used for all outcomes. Heterogeneity was assessed with I2 statistics. RESULTS Eight RCTs (1,300 patients) were included, of whom 650 (50%) underwent GA. Recanalization success was significantly higher in the GA group (OR 1.68; 95% CI 1.26-2.24; p < 0.04) than in CS. No significant difference between groups were found for good functional recovery (OR 1.13; IC 95% 0.76-1.67; p = 0.56), incidence of pneumonia (OR 1.23; IC 95% 0.56- 2,69; p = 0.61), three-month mortality (OR 0.99; IC 95% 0.73-1.34; p = 0.95), or cerebral hemorrhage (OR 0.97; IC 95% 0.68-1.38; p = 0.88). CONCLUSION Despite the increase in recanalization success rates in the GA group, GA and CS show similar rates of good functional recovery, three-month mortality, incidence of pneumonia, and cerebral hemorrhage in patients undergoing MT.
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Platogiannis N, Karelas D, Platogiannis D, Papanikolaou J. Aspiring use of a thrombectomy catheter for coronary air embolism aspiration. J Invasive Cardiol 2024; 36. [PMID: 38412441 DOI: 10.25270/jic/23.00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
A 52-year-old man with a history of percutaneous coronary intervention (PCI) in the left anterior descending (LAD) coronary artery was admitted for a facilitated PCI following an anterior ST-elevation myocardial infarction treated with thrombolysis at a nearby clinic.
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Affiliation(s)
| | - Dimitrios Karelas
- The Cardiology Department, Trikala Hospital, Trikala, Thessaly, Greece.
| | | | - John Papanikolaou
- The Cardiology Department, Trikala Hospital, Trikala, Thessaly, Greece
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Wang H, Shen P, Yu X, Shang Y, Xu J, Chen X, Tan M, Lin L, Parsons M, Zhang S, Geng Y. Asymmetric deep cerebral venous filling predicts poor outcome of acute basilar artery occlusion after endovascular treatment. CNS Neurosci Ther 2024; 30:e14513. [PMID: 37953498 PMCID: PMC11017399 DOI: 10.1111/cns.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE To explore the relationship between asymmetric deep cerebral venous (ADCV) filling and poor outcomes after endovascular treatment (EVT) in patients with acute basilar artery occlusion (ABAO). METHODS ABAO patients were selected from a prospectively collected data at our center. The DCV filling was evaluated using computed tomography perfusion (CTP)-derived reconstructed 4D-DSA or mean venous map. ADCV filling was defined as the internal cerebral vein (ICV), thalamostriate vein (TSV), or basal vein of Rosenthal (BVR) presence of ipsilateral filling defects or delayed opacification compared to the contralateral side. Poor prognosis was defined as a modified Rankin scale score >3 at the 90-day follow-up. RESULTS A total of 90 patients were enrolled in the study, with a median Glasgow Coma Scale of 6, 46 (51.1%) showed ADCV filling, 59 (65.6%) had a poor prognosis, and 27 (30.7%) had malignant cerebellar edema (MCE). Multivariate adjusted analysis revealed significant associations between asymmetric TSV and poor prognosis (odds ratio, 9.091, p = 0.006); asymmetric BVR (OR, 9.232, p = 0.001) and asymmetric ICV (OR, 4.028, p = 0.041) were significantly associated with MCE. CONCLUSION Preoperative ADCV filling is an independent influencing factor for the poor outcome after EVT in ABAO patients.
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Affiliation(s)
- Huiyuan Wang
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- School of Clinical Medicine, Graduate SchoolBengbu Medical CollegeBengbuChina
| | - Panpan Shen
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- The Second Clinical Medical CollegeZhejiang Traditional Chinese Medicine UniversityHangzhouChina
| | - Xinyue Yu
- Alberta InstituteWenzhou Medical UniversityWenzhouChina
| | - Yafei Shang
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- School of Clinical Medicine, Graduate SchoolBengbu Medical CollegeBengbuChina
| | - Jie Xu
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- The Second Clinical Medical CollegeZhejiang Traditional Chinese Medicine UniversityHangzhouChina
| | - Xinyi Chen
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
- The Second Clinical Medical CollegeZhejiang Traditional Chinese Medicine UniversityHangzhouChina
| | - Mingming Tan
- Department of Quality ManagementZhejiang Provincial People's HospitalHangzhouChina
| | - Longting Lin
- School of Medicine and Public HealthUniversity of NewcastleNew South WalesNewcastleAustralia
| | - Mark Parsons
- Department of Neurology, Liverpool HospitalUniversity of New South WalesNew South WalesSydneyAustralia
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of NeurologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouChina
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Uysal E, von Bodelschwingh B, Tabakci ON, Basarir CI, Bulut S. Combined Aspiration and Stent Retriever Thrombectomy for Distal Carotid Artery Occlusion Using Balloon Guide versus Non-Balloon Guide Catheter. J Clin Med 2024; 13:1978. [PMID: 38610743 PMCID: PMC11012368 DOI: 10.3390/jcm13071978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/17/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Background: The introduction of endovascular thrombectomy dramatically changed acute stroke management and became the standard treatment. Balloon guide catheters provide flow arrest during the clot retrieval process and have several advantages.This study aimed to compare balloon guide catheters (BGCs) versus non-balloon guide catheters (NBGCs) as a part of a combined treatment modality in patients presenting with acute ischemic stroke. Methods: This retrospective study included n = 65 patients who underwent a combined endovascular stroke treatment for distal internal carotid artery (ICA) occlusion. Patients underwent aspiration and stent retriever thrombectomy with the use of BGCs (Group 1, n = 27) or NBGCs (Group 2, n = 38). Results: The groups were compared for outcomes: the National Institutes of Health Stroke Scale (NIHSSS) score change, successful recanalization, good functional outcome at three months, and in-hospital mortality. Conclusion: The two groups didn't differ in terms of the NIHSS score change compared to baseline (p > 0.05). Moreover, there were no significant differences between the two groups in terms of the successful recanalization rate, three-month favorable functional outcome rate, and in-hospital mortality (p = 0.292, p = 0.952, p = 0.178), respectively. Further prospective studies with a larger number of patients and better methodology are warranted.
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Affiliation(s)
- Ender Uysal
- Radiology Clinic Antalya, Antalya Training and Research Hospital, University of Health Sciences, Antalya 07100, Turkey
| | - Bade von Bodelschwingh
- Radiology Clinic, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul 34098, Turkey; (B.v.B.); (O.N.T.)
| | - Omer Naci Tabakci
- Radiology Clinic, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul 34098, Turkey; (B.v.B.); (O.N.T.)
| | - Celal Ilker Basarir
- Neurology Clinic Istanbul, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul 34098, Turkey; (C.I.B.); (S.B.)
| | - Serpil Bulut
- Neurology Clinic Istanbul, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul 34098, Turkey; (C.I.B.); (S.B.)
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18
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Li W, Lin Y, Su K, Cai F, Zhang J, Lai X, Zheng X, Guo P, Hou X, Dai Y. Syringe-assisted test-aspiration with mechanical aspiration thrombectomy results in good safety and short-term outcomes in the treatment of patients with deep venous thrombosis. Vascular 2024:17085381241242164. [PMID: 38531094 DOI: 10.1177/17085381241242164] [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: 03/28/2024]
Abstract
OBJECTIVE To evaluate the short-term outcomes and safety of syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis. METHODS This was a single-center, retrospective study of hospitalized patients with iliofemoral and/or inferior vena caval deep venous thrombosis, excluding those with pulmonary embolism. We collected the following patient data from the electronic medical records: age, sex, provoked/unprovoked deep venous thrombosis, symptom duration, thrombosed segments, and the presence of a tumor, thrombophilia, diabetes, and/or iliac vein compression syndrome. Venography and computed tomographic venography were performed in all patients before the procedure. All patients underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy under local anesthesia and sedation, and all received low-molecular-weight heparin peri-operatively. All patients underwent implantation of an inferior vena caval filter. Rivaroxaban was administered post-procedure, instead of heparin, for 3-6 months, with lower extremity compression. RESULTS Overall, 29 patients with deep venous thrombosis underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy from January 2022 to October 2022 in our institution. Technical success (>70% thrombus resolution) was achieved in all patients, and using a single procedure in 25/29 patients (86%). Concomitant stenting was performed in 18/29 (62%) of the patients, and 21/29 (69%) underwent angioplasty. The median (interquartile range) procedure time was 110 min (100-122), the median intra-operative bleeding volume was 150 mL (120-180), and the median decrease in the hemoglobin concentration from pre- to post-operative was 7 g/L (4-14). The median follow-up duration was 7 months (5-9). All patients obtained symptomatic relief, and 27/29 achieved near-remission or full remission (combined total). No patients experienced peri-operative bleeding complications, or symptom recurrence or post-thrombectomy syndrome during follow-up. CONCLUSION The short-term outcomes following syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis were excellent, and the procedure was safe.
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Affiliation(s)
- Wanglong Li
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yichen Lin
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Kunfeng Su
- Department of Cardiovascular Surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Fujian, China
| | - Fanggang Cai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jinchi Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaoling Lai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaoqi Zheng
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Pingfan Guo
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xinhuang Hou
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yiquan Dai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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19
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Baker R, Bakali Z, Crocker JS, Mowla A, Smith M, Grossman A, Hagen MC, Prestigiacomo CJ, Shirani P. Tumor Embolic Stroke: The Importance of Pathological Assessment of Clots after Thrombectomy. J Clin Med 2024; 13:1834. [PMID: 38610599 PMCID: PMC11012646 DOI: 10.3390/jcm13071834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
While tumor emboli are a rare cause of stroke in cancer patients, they highlight the importance of gross observations and pathological assessments in the evaluation of clots. In this case report, a 70-year-old male with type 2 diabetes mellitus and coronary artery disease presented with acute left-sided weakness. He was clinically diagnosed with stroke and given alteplase at 1.5 h from last known normal. He then underwent CT angiography that showed right internal carotid artery occlusion and immediate thrombectomy. The recovered clot was white and lipid-like; due to its atypical appearance, it was sent for pathological assessment, where it was shown to bear features of malignancy. Subsequent imaging identified masses indicating malignancy in the left gluteus, right pleural hilum, and spine. Tumor embolic stroke is a rare pathology. Embolic diseases such as strokes and pulmonary embolisms are common in patients with cancer. Embolic stroke of undetermined source (ESUS) represents a significant portion of cancer strokes. Tumor emboli, though rare, may be an underappreciated source of ESUS in cancer patients. We intend for this case to demonstrate the value of pathological assessment for atypical thrombi as well as highlight the etiology of tumor embolic strokes.
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Affiliation(s)
- Richard Baker
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
| | - Zohabe Bakali
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
| | - Jeffrey S. Crocker
- Department of Pharmacology & Systems Physiology, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Ashkan Mowla
- Department of Neurosurgery, University of Southern California, Los Angeles, CA 90033, USA;
| | - Matthew Smith
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Aaron Grossman
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Matthew C. Hagen
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Pathology & Laboratory Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Charles J. Prestigiacomo
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Peyman Shirani
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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20
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Warman R, Warman P, Warman A, Bueso T, Ota R, Windisch T, Neves G. A deep learning method to identify and localize large-vessel occlusions from cerebral digital subtraction angiography. J Neuroimaging 2024. [PMID: 38506407 DOI: 10.1111/jon.13193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/25/2024] [Accepted: 01/27/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND AND PURPOSE An essential step during endovascular thrombectomy is identifying the occluded arterial vessel on a cerebral digital subtraction angiogram (DSA). We developed an algorithm that can detect and localize the position of occlusions in cerebral DSA. METHODS We retrospectively collected cerebral DSAs from a single institution between 2018 and 2020 from 188 patients, 86 of whom suffered occlusions of the M1 and proximal M2 segments. We trained an ensemble of deep-learning models on fewer than 60 large-vessel occlusion (LVO)-positive patients. We evaluated the model on an independent test set and evaluated the truth of its predicted localizations using Intersection over Union and expert review. RESULTS On an independent test set of 166 cerebral DSA frames with an LVO prevalence of 0.19, the model achieved a specificity of 0.95 (95% confidence interval [CI]: 0.90, 0.99), a precision of 0.7450 (95% CI: 0.64, 0.88), and a sensitivity of 0.76 (95% CI: 0.66, 0.91). The model correctly localized the LVO in at least one frame in 13 of the 14 LVO-positive patients in the test set. The model achieved a precision of 0.67 (95% CI: 0.52, 0.79), recall of 0.69 (95% CI: 0.46, 0.81), and a mean average precision of 0.75 (95% CI: 0.56, 0.91). CONCLUSION This work demonstrates that a deep learning strategy using a limited dataset can generate effective representations used to identify LVOs. Generating an expanded and more complete dataset of LVOs with obstructed LVOs is likely the best way to improve the model's ability to localize LVOs.
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Affiliation(s)
- Roshan Warman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - PranavI Warman
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Anmol Warman
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tulio Bueso
- Department of Neurology, Texas Tech University Medical Sciences Center, Lubbock, Texas, USA
| | - Riichi Ota
- Department of Neurology, Texas Tech University Medical Sciences Center, Lubbock, Texas, USA
| | - Thomas Windisch
- Department of Neurology, Texas Tech University Medical Sciences Center, Lubbock, Texas, USA
- Covenant Health, Lubbock, Texas, USA
| | - Gabriel Neves
- Department of Neurology, Section of Neurocritical Care, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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21
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Dittrich TD, von Streng T, Toebak AM, Zietz A, Wagner B, Hänsel M, Sutter R, Katan M, Peters N, Michels L, Kulcsár Z, Karwacki GM, Pileggi M, Cereda CW, Wegener S, Bonati LH, Psychogios M, De Marchis GM. Absent leptomeningeal collateralization is associated with greatest benefit from mechanical thrombectomy in the 6-24 hour time window. Eur Stroke J 2024:23969873241239208. [PMID: 38497536 DOI: 10.1177/23969873241239208] [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: 03/19/2024] Open
Abstract
INTRODUCTION The impact of leptomeningeal collateralization on the efficacy of mechanical thrombectomy (MT) in patients with anterior circulation large vessel occlusion (aLVO) presenting in the 6-24 h time window remains poorly elucidated. PATIENTS AND METHODS Retrospective multicenter study of aLVO patients presenting between 6 and 24 h after stroke onset who received MT plus Best Medical Treatment (BMT) or BMT alone. Leptomeningeal collateralization was assessed using single-phase computed tomography angiography (grade 0: no filling; grade 1: filling ⩽50%; grade 2: filling >50% but <100%; grade 3: filling 100% of the occluded territory). Inverse probability of treatment weighted ordinal regression was performed to assess the association between treatment and shift of the modified Rankin Scale (mRS) score toward lower categories at 3 months. We used interaction analysis to explore differential treatment effects on functional outcomes (probabilities for each mRS subcategory at 3 months) at different collateral grades. RESULTS Among 363 included patients, 62% received MT + BMT. Better collateralization was associated with better functional outcomes at 3 months in the BMT alone group (collateral grade 1 vs 0: acOR 5.06, 95% CI 2.33-10.99). MT + BMT was associated with higher odds of favorable functional outcome at 3 months (acOR 1.70, 95% CI 1.11-2.62) which was consistent after adjustment for collateral status (acOR 1.54, 95% CI 1.01-2.35). Regarding treatment effect modification, patients with absent collateralization had higher probabilities for a mRS of 0-4 and a lower mortality at 3 months for the MT + BMT group. DISCUSSION AND CONCLUSION In the 6-to-24-h time window, aLVO patients with absent leptomeningeal collateralization benefit most from MT + BMT, indicating potential advantages for this group despite their poorer baseline prognosis.
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Affiliation(s)
- Tolga D Dittrich
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Tennessee von Streng
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Anna M Toebak
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Martin Hänsel
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Raoul Sutter
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
- Medical Faculty, University Hospital Basel, Basel, Switzerland
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Medical Faculty, University Hospital Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Hirslanden Hospital Zurich, Zurich, Switzerland
| | - Lars Michels
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Zurich, Switzerland
| | - Zsolt Kulcsár
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Grzegorz M Karwacki
- Department of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Marco Pileggi
- Department of Neuroradiology EOC, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Carlo W Cereda
- Department of Neurology and Stroke Center EOC, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Rheinfelden Rehabilitation Clinic, Rheinfelden, Switzerland
| | - Marios Psychogios
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Medical Faculty, University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Medical Faculty, University Hospital Basel, Basel, Switzerland
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22
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Kato PJ, Kato J, Napier JA, Khorfan R, Aziz A. Unstable Carotid Artery Thrombus in a Patient With COVID-19 Infection. Vasc Endovascular Surg 2024:15385744241240543. [PMID: 38498941 DOI: 10.1177/15385744241240543] [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: 03/20/2024]
Abstract
We present a case of an unvaccinated, 43-year-old African American female patient with COVID-19 infection and clinical evidence of a left hemispheric stroke. A non-occlusive thrombus with a radiographic target lesion was identified on computed tomography angiography (CTA). A multi-disciplinary discussion regarding concern for embolization was provided due to its unstable nature, as well as evidence of recent stroke. Given her acute COVID-19 infection, symptomatology, and radiographic findings, it was concluded that the etiology of her stroke appeared most consistent with a hypercoagulable-related embolism rather than an atheroembolic event. The patient underwent left carotid artery thrombectomy with bovine patch angioplasty. Operative findings included: left carotid thrombus, minimal plaque after evacuation of the thrombus, and a small proximal internal carotid artery diameter. Given concern for stenosis with primary repair a bovine pericardial patch angioplasty was performed. We present a paradigm for extracranial carotid thrombectomy with therapeutic anticoagulation for COVID-related spontaneous arterial thrombosis.
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Affiliation(s)
- Patrick J Kato
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, USA
| | - Jesse Kato
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, USA
| | - Jarred A Napier
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, USA
| | - Rhami Khorfan
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, USA
| | - Abdulhameed Aziz
- Department of Surgery, Section of Vascular and Endovascular Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, USA
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23
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Caldwell J, Lee SSH, Sarrafzadeh M, Rhodes DS, McGuinness BJ. Flow reversal during stroke thrombectomy. Interv Neuroradiol 2024:15910199241238252. [PMID: 38489832 DOI: 10.1177/15910199241238252] [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: 03/17/2024] Open
Abstract
When performing mechanical thrombectomy for stroke patients, some physicians use balloon guide catheters (BGCs) in order to achieve flow reversal and thereby improve reperfusion quality. There is substantial evidence favoring the use of BGCs to improve reperfusion rates and clinical outcomes for thrombectomy patients; however, as we will outline in this review, there is also evidence that BGCs do not achieve reliable flow reversal in many circumstances. Therefore, if we are able to modify our techniques to improve the likelihood of flow reversal during thrombectomy maneuvers, we may be able to further improve reperfusion quality and clinical outcomes. This paper provides an overview of concepts on this topic and outlines some potential techniques to facilitate flow reversal more consistently, including a method to visually confirm it, with the aim of making iterative improvements towards optimal reperfusion for stroke patients.
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Affiliation(s)
- James Caldwell
- Department of Radiology, Auckland City Hospital, Grafton, Auckland, New Zealand
- FRANZCR, Auckland, New Zealand
| | - Shane S H Lee
- Department of Radiology, Auckland City Hospital, Grafton, Auckland, New Zealand
- FRANZCR, Auckland, New Zealand
| | - Mikal Sarrafzadeh
- Department of Radiology, Auckland City Hospital, Grafton, Auckland, New Zealand
- MBChB, Auckland, New Zealand
| | - Dave S Rhodes
- B.S. Mech. Eng, San Luis Obispo, CA, USA
- Engineered Outcomes, Redwood City, CA, USA
| | - Ben J McGuinness
- Department of Radiology, Auckland City Hospital, Grafton, Auckland, New Zealand
- FRANZCR, Auckland, New Zealand
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24
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Yang W, Hong SA, Kim JM, Jeong HB, Nam TK, Choi HH, Kim SM, Park KY, Kim HR. The immunologic phenotype of thrombi is associated with future vascular events after cerebral infarction. J Neurointerv Surg 2024; 16:352-358. [PMID: 37197936 DOI: 10.1136/jnis-2023-020155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Thrombi retrieved from patients with acute ischemic stroke may contain prognostic information. OBJECTIVE To investigate the relationship between the immunologic phenotype of thrombi and future vascular events in patients with a stroke. METHODS This study included patients with acute ischemic stroke who underwent endovascular thrombectomy at Chung-Ang University Hospital in Seoul, Korea, between February 2017 and January 2020. Laboratory and histological variables were compared between patients with and without recurrent vascular events (RVEs). Kaplan-Meier analysis followed by the Cox proportional hazards model was used to identify factors related to RVE. Receiver operating characteristic (ROC) analysis was conducted to evaluate the performance of the immunologic score by combining immunohistochemical phenotypes to predict RVE. RESULTS A total of 46 patients were included in the study with 13 RVEs (mean±SD age, 72.8±11.3 years; 26 (56.5%) men). Thrombi with a lower percentage of programmed death ligand-1 expression (HR=11.64; 95% CI 1.60 to 84.82) and a higher number of citrullinated histone H3 positive cells (HR=4.19; 95% CI 0.81 to 21.75) were associated with RVE. The presence of high-mobility group box 1 positive cell was associated with reduced risk of RVE, but the association was lost after adjustment for stroke severity. The immunologic score, which consists of the three immunohistochemical phenotypes, showed good performance in predicting RVE (area under the ROC curve, 0.858; 95% CI 0.758 to 0.958). CONCLUSIONS The immunological phenotype of thrombi could provide prognostic information after stroke.
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Affiliation(s)
- Wookjin Yang
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Soon Auck Hong
- Department of Pathology, Chung-Ang University Hospital, Seoul, Korea
| | - Jeong-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Hae-Bong Jeong
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Taek-Kyun Nam
- Department of Neurosurgery, Chung-Ang University Hospital, Seoul, Korea
| | - Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Seoul, Korea
| | - Suh Min Kim
- Department of Surgery, Chung-Ang University College of Medicine and Graduate School of Medicine, Seoul, Korea
| | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Hye Ryoun Kim
- Department of Laboratory Medicine, Chung-Ang University Hospital, Seoul, Korea
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25
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Yedavalli VS, Koneru M, Hoseinyazdi M, Greene C, Lakhani DA, Xu R, Luna LP, Caplan JM, Dmytriw AA, Guenego A, Heit JJ, Albers GW, Wintermark M, Gonzalez LF, Urrutia VC, Huang J, Nael K, Leigh R, Marsh EB, Hillis AE, Llinas RH. Prolonged venous transit on perfusion imaging is associated with higher odds of mortality in successfully reperfused patients with large vessel occlusion stroke. J Neurointerv Surg 2024:jnis-2024-021488. [PMID: 38471762 DOI: 10.1136/jnis-2024-021488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/02/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Poor venous outflow (VO) profiles are associated with unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO), despite achieving successful reperfusion. The objective of this study is to assess the association between mortality and prolonged venous transit (PVT), a novel visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps. METHODS We performed a retrospective analysis of prospectively collected data from consecutive adult patients with AIS-LVO with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s timing on CTP Tmax maps in at least one of the following: superior sagittal sinus (proximal venous drainage) and/or torcula (deep venous drainage). PVT- was defined as lacking this in both regions. The primary outcome was mortality at 90 days. In a 1:1 propensity score-matched cohort, regressions were performed to determine the effect of PVT on 90-day mortality. RESULTS In 127 patients of median (IQR) age 71 (64-81) years, mortality occurred in a significantly greater proportion of PVT+ patients than PVT- patients (32.5% vs 12.6%, P=0.01). This significant difference persisted after matching (P=0.03). PVT+ was associated with a significantly increased likelihood of 90-day mortality (OR 1.22 (95% CI 1.02 to 1.46), P=0.03) in the matched cohort. CONCLUSIONS PVT+ was significantly associated with 90-day mortality despite successful reperfusion therapy in patients with AIS-LVO. PVT is a simple VO profile marker with potential as an adjunctive metric during acute evaluation of AIS-LVO patients. Future studies will expand our understanding of using PVT in the evaluation of patients with AIS-LVO.
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Affiliation(s)
- Vivek S Yedavalli
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Manisha Koneru
- Department of Radiology, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Cynthia Greene
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Dhairya A Lakhani
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Risheng Xu
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Licia P Luna
- Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Justin M Caplan
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Neuroradiology and Neurointervention, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adrien Guenego
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
- Radiology, Stanford University, Palo Alto, California, USA
| | - Gregory W Albers
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
- Neurology, Stanford University, Palo Alto, California, USA
| | - Max Wintermark
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - L Fernando Gonzalez
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Judy Huang
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kambiz Nael
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Richard Leigh
- Neurology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | - Argye E Hillis
- Neurology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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26
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Feldmeier M, Kim AS, Zachrison KS, Alberts MJ, Shen YC, Hsia RY. Heterogeneity of State Stroke Center Certification and Designation Processes. Stroke 2024; 55:1051-1058. [PMID: 38469729 DOI: 10.1161/strokeaha.123.045368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/04/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification. METHODS In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category. RESULTS Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6). CONCLUSIONS Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.
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Affiliation(s)
- Madeline Feldmeier
- Department of Emergency Medicine, University of California, San Francisco. (M.F., R.Y.H.)
| | - Anthony S Kim
- Department of Neurology, UCSF Weill Institute of Neurosciences, University of California, San Francisco. (A.S.K.)
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston (K.S.Z.)
- Harvard Medical School, Boston, MA (K.S.Z.)
| | - Mark J Alberts
- Ayer Neuroscience Institute, Hartford HealthCare, CT (M.J.A.)
| | - Yu-Chu Shen
- Department of Defense Management, Naval Postgraduate School, Monterey, CA (Y.-C.S.)
- National Bureau of Economic Research, Cambridge, MA (Y.-C.S.)
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco. (M.F., R.Y.H.)
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. (R.Y.H.)
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Viticchi G, Falsetti L, Altamura C, Di Felice C, Vernieri F, Bartolini M, Silvestrini M. Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review. Rev Neurosci 2024; 0:revneuro-2024-0002. [PMID: 38459676 DOI: 10.1515/revneuro-2024-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Lorenzo Falsetti
- Clinica Medica, Clinical and Molecular Sciences Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Chiara Di Felice
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Marco Bartolini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
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Stanton K, Philippou H, Ariëns RA. Ischaemic Stroke, Thromboembolism and Clot Structure. Neuroscience 2024:S0306-4522(24)00088-5. [PMID: 38453129 DOI: 10.1016/j.neuroscience.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/19/2024] [Accepted: 02/23/2024] [Indexed: 03/09/2024]
Abstract
Ischaemic stroke is a major cause of morbidity and mortality worldwide. Blood clotting and thromboembolism play a central role in the pathogenesis of ischaemic stroke. An increasing number of recent studies indicate changes in blood clot structure and composition in patients with ischaemic stroke. In this review, we aim to summarise and discuss clot structure, function and composition in ischaemic stroke, including its relationships with clinical diagnosis and treatment options such as thrombolysis and thrombectomy. Studies are summarised in which clot structure and composition is analysed both in vitro from patients' plasma samples and ex vivo in thrombi obtained through interventional catheter-mediated thrombectomy. Mechanisms that drive clot composition and architecture such as neutrophil extracellular traps and clot contraction are also discussed. We find that, while in vitro clot structure in plasma samples from ischaemic stroke patients are consistently altered, showing denser clots that are more resistant to fibrinolysis, current data on the composition and architecture of ex vivo clots obtained by thrombectomy are more variable. With the potential of advances in technologies underpinning both the imaging and retrieving of clots, we expect that future studies in this area will generate new data that is of interest for the diagnosis, optimal treatment strategies and clinical management of patients with ischaemic stroke.
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Affiliation(s)
- Katherine Stanton
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Helen Philippou
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Robert As Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
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Wang J, Yang C, Zhang R, Hu W, Yang P, Jiang Y, Hong W, Shan R, Jiang Y. Development and validation of a predictive model for stroke associated pneumonia in patients after thrombectomy for acute ischemic stroke. Front Med (Lausanne) 2024; 11:1370986. [PMID: 38504915 PMCID: PMC10948544 DOI: 10.3389/fmed.2024.1370986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/22/2024] [Indexed: 03/21/2024] Open
Abstract
Objective This study aims to identify the risk factors associated with stroke-associated pneumonia (SAP) in patients who have undergone thrombectomy for acute ischemic stroke and to develop a nomogram chart model for predicting the occurrence of pneumonia. Methods Consecutive patients who underwent thrombectomy for acute ischemic stroke were enrolled from three hospitals at Taizhou Enze Medical Center. They were randomly divided into a training group and a validation group in a 7:3 ratio. The training group data was used to screen for effective predictive factors using LASSO regression. Multiple logistic regression was then conducted to determine the predictive factors and construct a nomogram chart. The model was evaluated using the validation group, analyzing its discrimination, calibration, and clinical decision curve. Finally, the newly constructed model was compared with the AIS-APS, A2DS2, ISAN, and PANTHERIS scores for acute ischemic stroke-associated pneumonia. Results Out of 913 patients who underwent thrombectomy, 762 were included for analysis, consisting of 473 males and 289 females. The incidence rate of SAP was 45.8%. The new predictive model was constructed based on three main influencing factors: NIHSS ≥16, postoperative LMR, and difficulty swallowing. The model demonstrated good discrimination and calibration. When applying the nomogram chart to threshold probabilities between 7 and 90%, net returns were increased. Furthermore, the AUC was higher compared to other scoring systems. Conclusion The constructed nomogram chart in this study outperformed the AIS-APS, A2DS2 score, ISAN score, and PANTHERIS score in predicting the risk of stroke-associated pneumonia in patients with acute ischemic stroke after thrombectomy. It can be utilized for clinical risk prediction of stroke-associated pneumonia in patients after thrombectomy for acute ischemic stroke.
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Affiliation(s)
- Jingying Wang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Chao Yang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Ruihai Zhang
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Wei Hu
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Peng Yang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Yiqing Jiang
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Weijun Hong
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Renfei Shan
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Yongpo Jiang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
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Palazzo P, Piechowiak EI, Heldner MR. Successful Thrombectomy of the Posterior Cerebral Artery P2 Segment in a 61-Year-Old Man with Acute Ischaemic Stroke: A Case Report. Am J Case Rep 2024; 25:e941441. [PMID: 38439524 PMCID: PMC10926235 DOI: 10.12659/ajcr.941441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 02/04/2024] [Accepted: 12/01/2023] [Indexed: 03/06/2024]
Abstract
BACKGROUND Acute ischemic stroke in the posterior cerebral artery (PCA) territory can lead to persistent disabling deficits. The PCA is divided into 4 segments. The P2 segment begins at the posterior communicating artery and curves around the midbrain and above the tentorium cerebelli. This report is of a 61-year-old man with acute ischemic stroke involving the left hippocampus treated with direct thrombectomy of the P2 segment of the PCA. CASE REPORT A 61-year-old white man presented with transient amnesia, aphasia, right-sided hemianopia, dizziness, and persistent acute memory deficits. Magnetic resonance imaging (MRI) showed a left hippocampal acute ischemic stroke with left PCA occlusion in the P2 segment. Despite a low National Institutes of Health Stroke Scale (NIHSS) score and the already-formed lesion in the hippocampus, successful stent retriever thrombectomy was performed due to a considerable perfusion-diffusion mismatch and a persistent potentially disabling neurocognitive deficit. Due to partial thrombus dislocation, occlusion of the common origin of the right posterior inferior cerebellar artery (PICA) and anterior inferior cerebellar artery (AICA) occurred and was immediately treated by thrombectomy to prevent severe cerebellar infarction. His clinical symptoms completely resolved and a neuropsychological exam showed no residual deficits. CONCLUSIONS Thrombectomy of the P2 segment of the PCA is feasible and can be considered to treat patients with acute occlusion at risk for persistent disabling deficits, based on clinical estimation of the impact of such deficits and the presence of potentially salvageable brain tissue. Potential procedural complications should be sought out and immediately treated, if technically feasible.
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Affiliation(s)
- Paola Palazzo
- Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Eike I. Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital and University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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Matsumoto Y, Akamatsu Y, Yoshida K, Ogasawara Y, Misaki T, Sasou S, Konno H, Ogasawara K. Acute large-vessel occlusion due to an infected thrombus formation induced by invasive sphenoid sinus aspergillosis: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE23733. [PMID: 38437683 PMCID: PMC10916845 DOI: 10.3171/case23733] [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] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/25/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND The authors describe a rare case of acute large-vessel occlusion due to an infected thrombus formation that was induced by invasive sphenoid sinus aspergillosis. OBSERVATIONS An 82-year-old man with a history of immunoglobulin G4-related disease and long-term use of steroids and immunosuppressants was admitted to the authors' hospital with severe right hemiparesis. Cerebral angiography revealed occlusion of the left internal carotid artery (ICA). He underwent thrombectomy, resulting in successful recanalization. However, severe stenosis was evident in the left ICA cavernous segment. Pathological analysis of the retrieved thrombus identified Aspergillus. Postoperative magnetic resonance imaging revealed sinusitis in the left sphenoid sinus as a possible source of the infection. The patient's general condition deteriorated during the course of hospitalization due to refractory aspiration pneumonia, and he died 46 days after thrombectomy. Pathological autopsy and histopathological investigation of the left ICA and the left sphenoid sinus showed that Aspergillus had invaded the wall of the left ICA from the adjacent sphenoid sinus. These findings indicate a diagnosis of acute large-vessel occlusion due to infected thrombus formation induced by invasive sphenoid sinus aspergillosis. LESSONS Pathological analysis of a retrieved thrombus appears useful for identifying rare stroke etiologies such as fungal infection.
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Affiliation(s)
| | - Yosuke Akamatsu
- Department of Neurosurgery, Iwate Medical University, Yahaba-cho, Iwate, Japan
| | | | - Yasushi Ogasawara
- Department of Neurosurgery, Iwate Medical University, Yahaba-cho, Iwate, Japan
| | | | - Shunichi Sasou
- Pathology, Hachinohe Red-Cross Hospital, Hachinohe, Aomori, Japan; and
| | | | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Yahaba-cho, Iwate, Japan
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Rossi FH, Osse FJ, Thorpe PE. The paradigm shift in treatment of severe venous thromboembolism. J Vasc Bras 2024; 24:e20230095. [PMID: 38487548 PMCID: PMC10939176 DOI: 10.1590/1677-5449.202300952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/02/2023] [Indexed: 03/17/2024] Open
Abstract
Pulmonary embolism (PE) is the third leading cause of cardiovascular death and the main cause of preventable in-hospital death in the world. The PERT® (Pulmonary Embolism Response Team) concept involves multidisciplinary diagnosis and immediate treatment. Deep venous thrombosis (DVT) is the initial cause of most cases of PE and is responsible for complications such as chronic thromboembolic recurrence, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension. An aggressive approach to severe cases of iliofemoral DVT similar to the PERT® system can not only reduce the immediate risk of PE and death but can also reduce later sequelae. New percutaneous techniques and mechanical thrombectomy devices for venous thromboembolism (VTE) have shown encouraging clinical results. We propose the development of an expanded concept of rapid response to VTE, which involves not only PE (PERT®) but also severe cases of DVT: the Venous Thromboembolism Response Team (VTERT®).
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Ospel JM, Boulouis G. Evolving Role of Imaging in Acute Ischemic Stroke Care. Stroke 2024; 55:765-768. [PMID: 38126180 DOI: 10.1161/strokeaha.123.044264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Johanna Maria Ospel
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, AB, Canada (J.M.O.)
| | - Grégoire Boulouis
- Diagnostic and Interventional Neuroradiology, Centre d'investigation Clinique, Innovation Technologique (CIC-IT) 1415, Centre Hospitalier Régional Universitaire de Tours (CHRU) de Tours, INSERM 1253 iBrain, Tours, France
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Che B, Kusuma Y, Bush S, Dowling R, Williams C, Houlihan C, Mitchell PJ, Yan B. Neurological Improvement by One-Thirds Is Associated With Early Recanalization in Stroke With Large Vessel Occlusion. Stroke 2024; 55:569-575. [PMID: 38323425 DOI: 10.1161/strokeaha.123.045504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND A proportion of large vessel occlusion strokes demonstrate early recanalization, obviating the initial intention to proceed to endovascular thrombectomy. Neurological improvement is a possible surrogate marker for reperfusion. We aimed to determine the optimal threshold of neurological improvement, as defined by the National Institutes of Health Stroke Scale (NIHSS), which best associates with early recanalization. METHODS We retrospectively analyzed consecutive patients with large vessel occlusion transferred from primary stroke centers to a tertiary comprehensive stroke center in Melbourne, Australia, for possible endovascular thrombectomy from January 2018 to December 2022. Absolute and percentage changes in NIHSS between transfer, as well as other definitions of neurological improvement, were compared using receiver operating characteristic curve analysis for association with recanalization as defined by the absence of occlusion in the internal carotid artery, middle cerebral artery (M1 or M2 segments), or basilar artery on repeat vascular imaging. RESULTS Six hundred and fifty-four transferred patients with large vessel occlusion were included in the analysis: mean age was 68.8±14.0 years, 301 (46.0%) were women, and 338 (52%) received intravenous thrombolytics. The proportion of extracranial internal carotid artery, intracranial internal carotid artery, M1, proximal M2, and basilar artery occlusion was 18.8%, 13.6%, 48.3%, 15.0%, and 4.3%, respectively, on initial computed tomography angiogram. Median NIHSSprimary stroke center and NIHSScomprehensive stroke center scores were 15 (interquartile range, 9-18) and 13 (interquartile range, 8-19), respectively. Early recanalization occurred in 82 (13%) patients. NIHSS reduction of ≥33% was the best tradeoff between sensitivity (64%) and specificity (83%) for identifying recanalization. NIHSS reduction of ≥33% had the highest discriminative ability to predict recanalization (area under the curve, 0.735) in comparison with other definitions of neurological improvement. CONCLUSIONS One-third neurological improvement between the primary hospital and tertiary center was the best predictor of early recanalization.
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Affiliation(s)
- Bizhong Che
- Melbourne Brain Centre (B.C., Y.K., C.W., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Yohanna Kusuma
- Melbourne Brain Centre (B.C., Y.K., C.W., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Steven Bush
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Richard Dowling
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Cameron Williams
- Melbourne Brain Centre (B.C., Y.K., C.W., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Conor Houlihan
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Peter J Mitchell
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Bernard Yan
- Melbourne Brain Centre (B.C., Y.K., C.W., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
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Weller J, Krzywicka K, van de Munckhof A, Dorn F, Althaus K, Bode FJ, Bandettini di Poggio M, Buck B, Kleinig T, Cordonnier C, Dizonno V, Duan J, Elkady A, Chew BLA, Garcia-Esperon C, Field TS, Legault C, Morin Martin M, Michalski D, Pelz J, Schoenenberger S, Nagel S, Petruzzellis M, Raposo N, Skjelland M, Zimatore DS, Aaron S, Sanchez van Kammen M, Aguiar de Sousa D, Lindgren E, Jood K, Scutelnic A, Heldner MR, Poli S, Arauz A, Conforto AB, Putaala J, Tatlisumak T, Arnold M, Coutinho JM, Günther A, Zimmermann J, Ferro JM. Endovascular treatment of cerebral sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia. Eur Stroke J 2024; 9:105-113. [PMID: 37771138 PMCID: PMC10916823 DOI: 10.1177/23969873231202363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/03/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION There is little data on the role of endovascular treatment (EVT) of cerebral venous sinus thrombosis (CVST) due to vaccine-induced immune thrombotic thrombocytopenia (VITT). Here, we describe clinical characteristics and outcomes of CVST-VITT patients who were treated with EVT. PATIENTS AND METHODS We report data from an international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 6 March 2023. VITT was defined according to the Pavord criteria. RESULTS EVT was performed in 18/136 (13%) patients with CVST-VITT (92% aspiration and/or stent retrieval, 8% local thrombolysis). Most common indications were extensive thrombosis and clinical or radiological deterioration. Compared to non-EVT patients, those receiving EVT had a higher median thrombus load (4.5 vs 3). Following EVT, local blood flow was improved in 83% (10/12, 95% confidence interval [CI] 54-96). One (6%) asymptomatic sinus perforation occurred. Eight (44%) patients treated with EVT also underwent decompressive surgery. Mortality was 50% (9/18, 95% CI 29-71) and 88% (8/9, 95% CI 25-66) of surviving EVT patients achieved functional independence with a modified Rankin Scale score of 0-2 at follow-up. In multivariable analysis, EVT was not associated with increased mortality (adjusted odds ratio, 0.66, 95% CI 0.16-2.58). DISCUSSION AND CONCLUSION We describe the largest cohort of CVST-VITT patients receiving EVT. Half of the patients receiving EVT died during hospital admission, but most survivors achieved functional independence.
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Affiliation(s)
- Johannes Weller
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | | | - Felix J Bode
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | | | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, AB, Canada
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, Lille, France
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jiangang Duan
- Department of Neurology and Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia
| | | | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Catherine Legault
- Division of Neurology, McGill University Health Centre, Montreal, QC, Canada
| | - Mar Morin Martin
- Department of Neurology, Hospital Complex of Toledo, Toledo, Spain
| | | | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Marco Petruzzellis
- Neuroradiology Unit, Azienda Ospedaliera Consorziale Policlinico di Bari, Italy
| | - Nicolas Raposo
- Department of Neurology, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France and Inserm, Toulouse NeuroImaging Center, Université de Toulouse, Toulouse, France
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Sanjith Aaron
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mayte Sanchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Stroke Centre, Lisbon Central University Hospital, Lisbon, Portugal
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
| | - Adriana B Conforto
- Hospital das Clinicas/São Paulo University and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - José M Ferro
- Centro de Estudas Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal
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Jhou HJ, Yang LY, Chen PH. Comment on the article 'Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis'. Eur Stroke J 2024; 9:274-275. [PMID: 38009691 PMCID: PMC10916817 DOI: 10.1177/23969873231216814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua
- School of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Li-Yu Yang
- School of Medicine, Kaohsiung Medical University, Kaohsiung
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhua
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City
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Xing L, Yilun Y, Ji Z, Wei C. Rare Case of Renal Epithelioid Angiomyolipoma With Tumor Thrombus Into the IVC and Right Atrium. Circ Cardiovasc Imaging 2024; 17:e016083. [PMID: 38288625 DOI: 10.1161/circimaging.123.016083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Affiliation(s)
- Luo Xing
- Department of Urology, Urologic Surgery Center, Xinqiao Hospital (L.X., Z.J., C.W.), Third Military Medical University (Army Medical University), Chongqing, China
| | - Yi Yilun
- College of Basic Medical Sciences (Y.Y.L), Third Military Medical University (Army Medical University), Chongqing, China
| | - Zheng Ji
- Department of Urology, Urologic Surgery Center, Xinqiao Hospital (L.X., Z.J., C.W.), Third Military Medical University (Army Medical University), Chongqing, China
| | - Chen Wei
- Department of Urology, Urologic Surgery Center, Xinqiao Hospital (L.X., Z.J., C.W.), Third Military Medical University (Army Medical University), Chongqing, China
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Katsanos AH, Joundi RA, Palaiodimou L, Ahmed N, Kim JT, Goyal N, Maier IL, de Havenon A, Anadani M, Matusevicius M, Mistry EA, Khatri P, Arthur AS, Sarraj A, Yaghi S, Shoamanesh A, Catanese L, Psychogios MN, Tsioufis K, Malhotra K, Spiotta AM, Sandset EC, Alexandrov AV, Petersen NH, Tsivgoulis G. Blood Pressure Trajectories and Outcomes After Endovascular Thrombectomy for Acute Ischemic Stroke. Hypertension 2024; 81:629-635. [PMID: 38164751 DOI: 10.1161/hypertensionaha.123.22164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Data on systolic blood pressure (SBP) trajectories in the first 24 hours after endovascular thrombectomy (EVT) in acute ischemic stroke are limited. We sought to identify these trajectories and their relationship to outcomes. METHODS We combined individual-level data from 5 studies of patients with acute ischemic stroke who underwent EVT and had individual blood pressure values after the end of the procedure. We used group-based trajectory analysis to identify the number and shape of SBP trajectories post-EVT. We used mixed effects regression models to identify associations between trajectory groups and outcomes adjusting for potential confounders and reported the respective adjusted odds ratios (aORs) and common odds ratios. RESULTS There were 2640 total patients with acute ischemic stroke included in the analysis. The most parsimonious model identified 4 distinct SBP trajectories, that is, general directional patterns after repeated SBP measurements: high, moderate-high, moderate, and low. Patients in the higher blood pressure trajectory groups were older, had a higher prevalence of vascular risk factors, presented with more severe stroke syndromes, and were less likely to achieve successful recanalization after the EVT. In the adjusted analyses, only patients in the high-SBP trajectory were found to have significantly higher odds of early neurological deterioration (aOR, 1.84 [95% CI, 1.20-2.82]), intracranial hemorrhage (aOR, 1.84 [95% CI, 1.31-2.59]), mortality (aOR, 1.75 [95% CI, 1.21-2.53), death or disability (aOR, 1.63 [95% CI, 1.15-2.31]), and worse functional outcomes (adjusted common odds ratio,1.92 [95% CI, 1.47-2.50]). CONCLUSIONS Patients follow distinct SBP trajectories in the first 24 hours after an EVT. Persistently elevated SBP after the procedure is associated with unfavorable short-term and long-term outcomes.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., R.A.J., A.S., L.C.)
| | - Raed A Joundi
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., R.A.J., A.S., L.C.)
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon University Hospital, School of Medicine (L.P., G.T.), National and Kapodistrian University of Athens, Greece
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., M.M.)
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (N.A., M.M.)
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea (J.-T.K.)
| | - Nitin Goyal
- Department of Neurology (N.G., G.T., A.V.A.), University of Tennessee Health Science Center, Memphis
- Department of Neurosurgery (N.G., A.S.A.), University of Tennessee Health Science Center, Memphis
| | - Ilko L Maier
- Department of Neurology, University Medical Center Goettingen, Germany (I.L.M.)
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City (A.d.H.)
| | - Mohammad Anadani
- Department of Neurology, (M.A.), Medical University of South Carolina, Charleston
- Department of Neurosurgery (MA., A.M.S.), Medical University of South Carolina, Charleston
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (N.A., M.M.)
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (N.A., M.M.)
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee (E.A.M.)
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Ohio (P.K.)
| | - Adam S Arthur
- Department of Neurosurgery (N.G., A.S.A.), University of Tennessee Health Science Center, Memphis
| | - Amrou Sarraj
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., R.A.J., A.S., L.C.)
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY (S.Y.)
| | - Ashkan Shoamanesh
- Department of Neurology, Case Western Reserve University, University Hospitals Cleveland Medical Center, OH (A.S.)
| | - Luciana Catanese
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Canada (A.H.K., R.A.J., A.S., L.C.)
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland (M.-N.P.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippokration Hospital (K.T.), National and Kapodistrian University of Athens, Greece
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania (K.M.)
| | - Alejandro M Spiotta
- Department of Neurosurgery (MA., A.M.S.), Medical University of South Carolina, Charleston
| | | | - Andrei V Alexandrov
- Department of Neurology (N.G., G.T., A.V.A.), University of Tennessee Health Science Center, Memphis
| | - Nils H Petersen
- Department of Neurology, Yale University, New Haven (N.H.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine (L.P., G.T.), National and Kapodistrian University of Athens, Greece
- Department of Neurology (N.G., G.T., A.V.A.), University of Tennessee Health Science Center, Memphis
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Heitkamp C, Winkelmeier L, Heit JJ, Albers GW, Lansberg MG, Kniep H, Broocks G, Stracke CP, Schell M, Guenego A, Paech D, Wintermark M, Fiehler J, Faizy TD. Early neurological deterioration in patients with acute ischemic stroke is linked to unfavorable cerebral venous outflow. Eur Stroke J 2024; 9:162-171. [PMID: 38069665 PMCID: PMC10916832 DOI: 10.1177/23969873231208277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/29/2023] [Indexed: 03/06/2024] Open
Abstract
INTRODUCTION Early neurological deterioration (END) is associated with poor outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Causes of END after mechanical thrombectomy (MT) include unsuccessful recanalization and reperfusion hemorrhages. However, little is known about END excluding the aforementioned causes. We aimed to investigate factors associated with unexplained END (ENDunexplained) with regard to the cerebral collateral status. PATIENTS AND METHODS Multicenter retrospective study of AIS-LVO patients with successful MT (mTICI 2b-3). On admission CT angiography (CTA), pial arterial collaterals and venous outflow (VO) were assessed using the modified Tan-Scale and the Cortical Vein Opacification Score (COVES), respectively. ENDunexplained was defined as an increase in NIHSS score of ⩾ 4 within the first 24 hours after MT without parenchymal hemorrhage on follow-up imaging. Multivariable regression analyses were performed to examine factors of ENDunexplained and unfavorable functional outcome (modified Rankin Scale score 3-6). RESULTS A total of 620 patients met the inclusion criteria. ENDunexplained occurred in 10% of patients. While there was no significant difference in pial arterial collaterals, patients with ENDunexplained exhibited more often unfavorable VO (81% vs. 53%; P < 0.001). Unfavorable VO (aOR [95% CI]; 2.56 [1.02-6.40]; P = 0.045) was an independent predictor of ENDunexplained. ENDunexplained was independently associated with unfavorable functional outcomes at 90 days (aOR [95% CI]; 6.25 [2.06-18.94]; P = 0.001). DISCUSSION AND CONCLUSION Unfavorable VO on admission CTA was associated with ENDunexplained. ENDunexplained was independently linked to unfavorable functional outcomes at 90 days. Identifying AIS-LVO patients at risk of ENDunexplained may help to select patients for intensified monitoring and guide to optimal treatment regimes.
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Affiliation(s)
- Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Christian Paul Stracke
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Adrien Guenego
- Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
| | - Daniel Paech
- Clinic for Neuroradiology, University Hospital Bonn, Germany
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
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Yen HC, Pan GS, Jeng JS, Chen WS. Impact of Early Mobilization on Patients With Acute Ischemic Stroke Treated With Thrombolysis or Thrombectomy: A Randomized Controlled Trial. Neurorehabil Neural Repair 2024:15459683241236443. [PMID: 38426480 DOI: 10.1177/15459683241236443] [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: 03/02/2024]
Abstract
BACKGROUND Early mobilization (EM) within 24 to 72 hours post-stroke may improve patients' performance and ability. However, after intravenous thrombolysis (IVT) or mechanical thrombectomy (MT), the increased risk of hemorrhagic complications impacts the implementation of early out-of-bed mobilization. Few studies have investigated EM after IVT or MT for acute ischemic stroke (AIS), and its impact in these patients is unknown. OBJECTIVE To investigate the effect of EM on AIS treated with IVT or MT.|. METHODS We recruited 122 patients with first AIS; 60 patients were treated with IVT, and 62 patients were treated with MT. For each IVT and MT cohort, the control groups received standard early rehabilitation, and the intervention groups received an EM protocol. The training lasted 30 minutes/day, 5 days/week until discharge. MAIN OUTCOMES MEASURES The effectiveness of the interventions was evaluated using the motor domain of the Functional Independence Measure (FIM-motor) and the Postural Assessment Scale for Stroke Patients (PASS) at baseline, 2-week, 4-week, and 3-month post-stroke, the Functional Ambulation Category 2-week post-stroke, and the total length of stay at the stroke center. RESULTS Both IVT and MT treatment groups showed improved FIM-motor and PASS scores over time; however, only the IVT EM group had significantly improved FIM-motor performance within 1 month after stroke than the control group. Conclusion. An EM protocol with the same intervention time and session frequency per day as in the standard care protocol was effective in improving the functional ability of stroke patients after IVT.
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Affiliation(s)
- Hsiao-Ching Yen
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Guan-Shuo Pan
- Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center & Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Shiang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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Yabalak A, Ögün MN, Önalan A, Yılmaz M, Tokmak H, Ersoy S, Bilgili F, Bakkal T. Evaluation of the relationship between computed tomography angiography collateral scores and clinical outcome. Arq Neuropsiquiatr 2024; 82:1-7. [PMID: 38438069 PMCID: PMC10911890 DOI: 10.1055/s-0044-1779268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/11/2023] [Indexed: 03/06/2024]
Abstract
BACKGROUND The relationship between collateral circulation and prognosis after endovascular treatment in anterior circulation strokes has been reported in many studies. OBJECTIVE In this study, we aimed to compare the predictive power of clinical outcome by comparing five different collateral scores that are frequently used. METHODS Among the patients who underwent endovascular treatment in our clinic between November 2019 and December 2021, patients with premorbid mRS < 3, intracranial ICA and/or MCA M1 occlusion, and a pre-procedural multiphase CTA examination were included in the study. Demographic, technical, and duration information about the procedure, major events after the procedure, and clinical outcomes at 3 months were recorded. The mCTA, Tan, Maas, Miteff, and rLMC collateral scores of the patients were evaluated. RESULTS Clinical outcome at 3 months were good in 37 of the 68 patients included in the study (mRS ≤ 2). Only the mCTA and rLMC collateral scores were statistically significantly higher in those with a good clinical outcome. Significant correlation with 3-month mRS was detected only in mCTA and rLMC scores. Although rLMC and mCTA collateral scores showed a statistically significant association with prognosis, they were not sufficient to be an independent predictor of prognosis. CONCLUSION mCTA and rLMC were found to have the highest predictive power of clinical outcome and the highest correlation with the 3-month clinical outcome. Our study suggests that it would be beneficial to develop a new scoring system over multiphase CTA, which combines regional and temporal evaluation, which are the strengths of both collateral scoring.
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Affiliation(s)
- Ahmet Yabalak
- Duzce University, Faculty of Medicine, Department of Neurology, Duzce, Türkiye.
| | - Muhammed Nur Ögün
- Bolu Abant Izzet Baysal University, Department of Neurology, Bolu, Türkiye.
| | - Ayşenur Önalan
- Kartal Lutfi Kırdar City Hospital, Department of Neurology, Istanbul, Türkiye.
| | - Murat Yılmaz
- Bolu Abant Izzet Baysal University, Department of Neurology, Bolu, Türkiye.
| | - Hilmiye Tokmak
- Bolu Abant Izzet Baysal University, Department of Neurology, Bolu, Türkiye.
| | - Sadettin Ersoy
- Bolu Abant Izzet Baysal University, Department of Neurology, Bolu, Türkiye.
| | - Fatma Bilgili
- Bolu Abant Izzet Baysal University, Department of Neurology, Bolu, Türkiye.
| | - Tahsin Bakkal
- Bolu Abant Izzet Baysal University, Department of Neurology, Bolu, Türkiye.
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Cho MS, Javed Z, Patel R, Karim MS, Chan MR, Astor BC, Gardezi AI. Impact of COVID-19 pandemic on hemodialysis access thrombosis. J Vasc Access 2024; 25:467-473. [PMID: 35953895 PMCID: PMC9379590 DOI: 10.1177/11297298221116236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Delay in care of suspected stenosis or thrombosis can increase the chance of losing a functioning hemodialysis access. Access to care and resources were restricted during the COVID-19 pandemic. To evaluate the impact of the pandemic on arteriovenous fistula (AVF) and arteriovenous graft (AVG) procedures we have assessed the number and success of thrombectomies done before and during the COVID-19 pandemic. METHODS We examined all AVF and AVG angiograms with and without interventions, including thrombectomies, performed at a single center during April 2017-March 2021 (pre-COVID-19 era) and April 2020-March 2021 (COVID-19 era). RESULTS The proportion of procedures that were thrombectomies was higher during the COVID-19 era compared to the pre-COVID-19 era (13.3% vs 8.7%, p = 0.009). The proportion of thrombectomy procedures was higher during COVID-19 for AVF (8.2% vs 3.0%, p < 0.001) but there was no difference for AVG (26.5% vs 27%, p = 0.99). There was a trend toward a higher likelihood of unsuccessful thrombectomy during COVID-19 (33.3% vs 20.4%, p = 0.08). CONCLUSIONS More dialysis access thromboses and unsuccessful thrombectomies were noted during the COVID-19 pandemic. This difference could be due to a delay in patients getting procedures to maintain their dialysis accesses.
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Affiliation(s)
- Min S Cho
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Zain Javed
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Ravi Patel
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Muhammad S Karim
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Micah R Chan
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Brad C Astor
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
- Department of Population Health
Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Ali I Gardezi
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
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Radu RA, Costalat V, Fahed R, Ghozy S, Siegler JE, Shaikh H, Khalife J, Abdalkader M, Klein P, Nguyen TN, Heit JJ, Sweid A, El Naamani K, Regenhardt RW, Diestro JDB, Cancelliere NM, Amllay A, Meyer L, Dusart A, Bellante F, Forestier G, Rouchaud A, Saleme S, Mounayer C, Fiehler J, Kühn AL, Puri AS, Dyzmann C, Kan PT, Colasurdo M, Marnat G, Berge J, Barreau X, Sibon I, Nedelcu S, Henninger N, Kyheng M, Marotta TR, Stapleton CJ, Rabinov JD, Ota T, Dofuku S, Yeo LLL, Tan BYQ, Martinez-Gutierrez JC, Salazar-Marioni S, Sheth S, Renieri L, Capirossi C, Mowla A, Tjoumakaris SI, Jabbour P, Khandelwal P, Biswas A, Clarençon F, Elhorany M, Premat K, Valente I, Pedicelli A, Pedro Filipe J, Varela R, Quintero-Consuegra M, Gonzalez NR, Möhlenbruch MA, Jesser J, Tancredi I, ter Schiphorst A, Yedavalli V, Harker P, Chervak LM, Aziz Y, Gory B, Paul Stracke C, Hecker C, Killer-Oberpfalzer M, Griessenauer CJ, Thomas AJ, Hsieh CY, Liebeskind DS, Alexandre AM, Faizy TD, Weyland C, Patel AB, Pereira VM, Lubicz B, Dmytriw AA, Guenego A. First pass effect as an independent predictor of functional outcomes in medium vessel occlusions: An analysis of an international multicenter study. Eur Stroke J 2024; 9:114-123. [PMID: 37885243 PMCID: PMC10916815 DOI: 10.1177/23969873231208276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/15/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION First pass effect (FPE), achievement of complete recanalization (mTICI 2c/3) with a single pass, is a significant predictor of favorable outcomes for endovascular treatment (EVT) in large vessel occlusion stroke (LVO). However, data concerning the impact on functional outcomes and predictors of FPE in medium vessel occlusions (MeVO) are scarce. PATIENTS AND METHODS We conducted an international retrospective study on MeVO cases. Multivariable logistic modeling was used to establish independent predictors of FPE. Clinical and safety outcomes were compared between the two study groups (FPE vs non-FPE) using logistic regression models. Good outcome was defined as modified Rankin Scale 0-2 at 3 months. RESULTS Eight hundred thirty-six patients with a final mTICI ⩾ 2b were included in this analysis. FPE was observed in 302 patients (36.1%). In multivariable analysis, hypertension (aOR 1.55, 95% CI 1.10-2.20) and lower baseline NIHSS score (aOR 0.95, 95% CI 0.93-0.97) were independently associated with an FPE. Good outcomes were more common in the FPE versus non-FPE group (72.8% vs 52.8%), and FPE was independently associated with favorable outcome (aOR 2.20, 95% CI 1.59-3.05). 90-day mortality and intracranial hemorrhage (ICH) were significantly lower in the FPE group, 0.43 (95% CI, 0.25-0.72) and 0.55 (95% CI, 0.39-0.77), respectively. CONCLUSION Over 2/3 of patients with MeVOs and FPE in our cohort had a favorable outcome at 90 days. FPE is independently associated with favorable outcomes, it may reduce the risk of any intracranial hemorrhage, and 3-month mortality.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Robert Fahed
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Mohamad Abdalkader
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Piers Klein
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Ahmad Sweid
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Jose Danilo Bengzon Diestro
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael’s Hospital, Toronto, ON, Canada
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael’s Hospital, Toronto, ON, Canada
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Dusart
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Flavio Bellante
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Géraud Forestier
- University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Aymeric Rouchaud
- University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Suzana Saleme
- University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Charbel Mounayer
- University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Luisa Kühn
- Department of Radiology, University of Massachusetts Memorial Hospital, Worcester, MA, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Memorial Hospital, Worcester, MA, USA
| | - Christian Dyzmann
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Sana Klinik Lübeck, Lübeck, Germany
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Marco Colasurdo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Gaultier Marnat
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Jérôme Berge
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Barreau
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Simona Nedelcu
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Maéva Kyheng
- Department of Biostatistics, CHU Lille, Lille, France
| | - Thomas R Marotta
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael’s Hospital, Toronto, ON, Canada
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shogo Dofuku
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Leonard LL Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin YQ Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | | | | | - Sunil Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Carolina Capirossi
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Priyank Khandelwal
- Department of Endovascular Neurosurgery and Neuroradiology, NJMS, Newark, NJ, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital. Paris. France; GRC BioFast, Sorbonne University, Paris VI, France
| | - Mahmoud Elhorany
- Department of Neuroradiology, Pitié-Salpêtrière Hospital. Paris. France; GRC BioFast, Sorbonne University, Paris VI, France
- Neurology Department, Faculty of Medicine, Tanta University, Egypt
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital. Paris. France; GRC BioFast, Sorbonne University, Paris VI, France
| | - Iacopo Valente
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Markus A Möhlenbruch
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Illario Tancredi
- Department of Radiology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Adrien ter Schiphorst
- Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Vivek Yedavalli
- Division of Neuroradiology, Department of Radiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Lina M Chervak
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Yasmin Aziz
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Benjamin Gory
- Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
| | - Christian Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany
| | - Constantin Hecker
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Ajith J Thomas
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - David S Liebeskind
- UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Charlotte Weyland
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael’s Hospital, Toronto, ON, Canada
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael’s Hospital, Toronto, ON, Canada
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
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Marnat G, Lapergue B, Gory B, Kyheng M, Labreuche J, Turc G, Olindo S, Sibon I, Caroff J, Smadja D, Chausson N, Clarençon F, Seners P, Bourcier R, Pop R, Olivot JM, Mazighi M, Moulin S, Janot K, Cognard C, Alamowitch S, Gerschenfeld G. Intravenous thrombolysis with tenecteplase versus alteplase combined with endovascular treatment of anterior circulation tandem occlusions: A pooled analysis of ETIS and TETRIS. Eur Stroke J 2024; 9:124-134. [PMID: 37837202 PMCID: PMC10916828 DOI: 10.1177/23969873231206894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Tandem occlusions are a singular large vessel occlusion entity involving specific endovascular and perioperative antithrombotic management. In this context, data on safety and efficacy of prior intravenous thrombolysis (IVT) with tenecteplase is scarce. We aimed to compare IVT with tenecteplase or alteplase in patients with acute tandem occlusions intended for endovascular treatment. PATIENTS AND METHODS A retrospective pooled analysis of two large observational registries (ETIS (Endovascular Treatment of Ischemic Stroke) and TETRIS (Tenecteplase Treatment in Ischemic Stroke)) was performed on consecutive patients presenting with anterior circulation tandem occlusion treated with IVT using either alteplase (ETIS) or tenecteplase (TETRIS) followed by endovascular treatment between January 2015 and June 2022. Sensitivity analyses on atherosclerosis related tandem occlusions and on patient treated with emergent carotid stenting were conducted. Propensity score overlap weighting analyses were performed. RESULTS We analyzed 753 patients: 124 in the tenecteplase and 629 in the alteplase group. The overall odds of favorable outcome (3-month modified Rankin score 0-2) were comparable between both groups (49.4% vs 47.1%; OR = 1.10, 95%CI 0.85-1.41). Early recanalization, final successful recanalization and mortality favored the use of tenecteplase. The occurrence of any intracranial hemorrhage (ICH) was more frequent after tenecteplase use (OR = 2.24; 95%CI 1.75-2.86). However, risks of symptomatic ICH and parenchymal hematoma remained similar. In atherosclerotic tandems, favorable outcome, mortality, parenchymal hematoma, early recanalization, and final successful recanalization favored the tenecteplase group. In the carotid stenting subgroup, PH were less frequent in the tenecteplase group (OR = 0.18; 95%CI 0.05-0.69). CONCLUSION In patients with tandem occlusions, IVT with tenecteplase seemed reasonably safe in particular with increased early recanalization rates. These findings remain preliminary and should be further confirmed in randomized trials.
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Affiliation(s)
- Gaultier Marnat
- Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | | | - Benjamin Gory
- Neuroradiology, Nancy University Hospital, Université de Lorraine, IADI, INSERM U1254, Nancy, France
| | - Maeva Kyheng
- Biostatistics, Lille University Hospital, Lille, France
| | | | - Guillaume Turc
- Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | | | - Igor Sibon
- Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Jildaz Caroff
- Interventional Neuroradiology − NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Didier Smadja
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | - Nicolas Chausson
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | | | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | | | - Raoul Pop
- Neuroradiology, Strasbourg University Hospital, Strasbourg, France
| | | | - Mikael Mazighi
- Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris Cité, INSERM 1144, FHU Neurovasc, Paris, France
| | - Solène Moulin
- Neurology, Stroke Unit; Reims University Hospital, Reims, France
| | - Kevin Janot
- Neuroradiology, Tours University Hospital, Tours, France
| | | | - Sonia Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Gaspard Gerschenfeld
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
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Tan M, Vedantham S, Narayanan S, Parsi K, Davies AH. Interventional treatment for acute iliofemoral deep venous thrombosis. Phlebology 2024; 39:139-142. [PMID: 37909472 PMCID: PMC10878000 DOI: 10.1177/02683555231211080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Affiliation(s)
- Matthew Tan
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Kurosh Parsi
- Department of Dermatology, St. Vincent’s Hospital, Sydney, NSW, Australia
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
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Chen CH, Lee CW, Hsieh YC, Lin CJ, Chen YW, Lin KH, Sung PS, Tang CW, Chu HJ, Tsai KC, Chou CL, Lin CH, Wei CY, Yen SY, Chen PL, Yeh HL, Chan L, Sung SF, Lee M, Liu HM, Lin YH, Lee IH, Yeh SJ, Lien LM, Chiou HY, Lee JT, Tang SC, Jeng JS. Comparing Low- or Standard-Dose Alteplase in Endovascular Thrombectomy: Insights From a Nationwide Registry. Stroke 2024; 55:532-540. [PMID: 38314590 PMCID: PMC10896194 DOI: 10.1161/strokeaha.123.045851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/15/2023] [Accepted: 12/15/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Timely intravenous thrombolysis and endovascular thrombectomy are the standard reperfusion treatments for large vessel occlusion stroke. Currently, it is unknown whether a low-dose thrombolytic agent (0.6 mg/kg alteplase) can offer similar efficacy to the standard dose (0.9 mg/kg alteplase). METHODS We enrolled consecutive patients in the multicenter Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke who had received combined thrombolysis (within 4.5 hours of onset) and thrombectomy treatment from January 2019 to April 2023. The choice of low- or standard-dose alteplase was based on the physician's discretion. The outcomes included successful reperfusion (modified Thrombolysis in Cerebral Infarction score, 2b-3), symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score, and 90-day mortality. The outcomes between the 2 groups were compared using multivariable logistic regression and inverse probability of treatment weighting-adjusted analysis. RESULTS Among the 2242 patients in the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke, 734 (33%) received intravenous alteplase. Patients in the low-dose group (n=360) were older, had more women, more atrial fibrillation, and longer onset-to-needle time compared with the standard-dose group (n=374). In comparison to low-dose alteplase, standard-dose alteplase was associated with a lower rate of successful reperfusion (81% versus 87%; adjusted odds ratio, 0.63 [95% CI, 0.40-0.98]), a numerically higher incidence of symptomatic intracerebral hemorrhage (6.7% versus 3.9%; adjusted odds ratio, 1.81 [95% CI, 0.88-3.69]), but better 90-day modified Rankin Scale score (functional independence [modified Rankin Scale score, 0-2], 47% versus 31%; adjusted odds ratio, 1.91 [95% CI, 1.28-2.86]), and a numerically lower mortality rate (9% versus 15%; adjusted odds ratio, 0.73 [95% CI, 0.43-1.25]) after adjusting for covariates. Similar results were observed in the inverse probability of treatment weighting-adjusted models. The results were consistent across predefined subgroups and age strata. CONCLUSIONS Despite the lower rate of successful reperfusion and higher risk of symptomatic intracerebral hemorrhage with standard-dose alteplase, standard-dose alteplase was associated with a better functional outcome in patients receiving combined thrombolysis and thrombectomy.
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Affiliation(s)
- Chih-Hao Chen
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Chung-Wei Lee
- Medical Imaging (C.-W.L., Y.-H.L.), National Taiwan University Hospital, Taipei
| | - Yi-Chen Hsieh
- Program in Medical Neuroscience (Y.-C.H.), Taipei Medical University, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan (C.-J.L., I.-H.L)
| | - Yu-Wei Chen
- Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan (Y.-W.C.)
| | - Kuan-Hung Lin
- Department of Neurology, Chi Mei Medical Center, Tainan, Taiwan (K.-H.L.)
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (P.-S.S.)
| | - Chih-Wei Tang
- Department of Neurology, Far Eastern Memorial Hospital, New Taipei City, Taiwan (C.-W.T.)
| | - Hai-Jui Chu
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan (H.-J.C.)
| | - Kun-Chang Tsai
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City (K.-C.T.)
| | - Chao-Liang Chou
- Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan (C.-L.C.)
| | - Ching-Huang Lin
- Department of Neurology, Kaohsiung Veterans General Hospital, Taiwan (C.-H.L.)
| | - Cheng-Yu Wei
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhwa County, Taiwan (C.-Y.W.)
| | - Shang-Yih Yen
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (S.-Y.Y., J.-T.L.)
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taiwan (P.-L.C.)
| | - Hsu-Ling Yeh
- Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan (H.-L.Y., L.-M.L.)
| | - Lung Chan
- Department of Neurology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan (L.C.)
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan (S.-F.S.)
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Chiayi County, Taiwan (M.L.)
| | - Hon-Man Liu
- Department of Medical Imaging, Fu Jen Catholic University Hospital, New Taipei City, Taiwan (H.-M.L.)
| | - Yen-Heng Lin
- Medical Imaging (C.-W.L., Y.-H.L.), National Taiwan University Hospital, Taipei
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taiwan (C.-J.L., I.-H.L)
| | - Shin-Joe Yeh
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Li-Ming Lien
- Department of Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan (H.-L.Y., L.-M.L.)
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health, (H.-Y.C.), Taipei Medical University, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (S.-Y.Y., J.-T.L.)
| | - Sung-Chun Tang
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
| | - Jiann-Shing Jeng
- Departments of Neurology (C.-H.C., S.-J.Y., S.-C.T., J.-S.J.), National Taiwan University Hospital, Taipei
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Ali M, Dekker L, Daems JD, Ali M, van Zwet EW, Steyerberg EW, Duvekot MHC, Nguyen TTM, Moudrous W, van de Wijdeven RM, Visser MC, de Laat KF, Kerkhoff H, van den Wijngaard IR, Dippel DWJ, Roozenbeek B, Kruyt ND, Wermer MJH. Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients With Suspected Stroke. Stroke 2024; 55:548-554. [PMID: 38299328 PMCID: PMC10896195 DOI: 10.1161/strokeaha.123.044898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex differences in diagnostic performance of 8 prehospital scales to detect aLVO. METHODS We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS [Leiden Prehospital Stroke Study] and PRESTO [Prehospital Triage of Patients With Suspected Stroke Study]) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women. RESULTS Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 [9%] women and 131/1244 [11%] men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65-0.75) to 0.77 (95% CI, 0.73-0.82) in women versus 0.69 (95% CI, 0.64-0.73) to 0.75 (95% CI, 0.71-0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20-0.27) to 0.29 (95% CI, 0.26-0.31) in women versus 0.29 (95% CI, 0.24-0.33) to 0.37 (95% CI, 0.32-0.43) in men. Negative predictive values were similar (0.95 [95% CI, 0.94-0.96] to 0.98 [95% CI, 0.97-0.98] in women versus 0.94 [95% CI, 0.93-0.95] to 0.96 [95% CI, 0.94-0.97] in men). Sensitivity of the scales was slightly higher in women than in men (0.53 [95% CI, 0.43-0.63] to 0.76 [95% CI, 0.68-0.84] versus 0.49 [95% CI, 0.40-0.57] to 0.63 [95% CI, 0.55-0.73]), whereas specificity was lower (0.79 [95% CI, 0.76-0.81] to 0.87 [95% CI, 0.84-0.89] versus 0.82 [95% CI, 0.79-0.84] to 0.90 [95% CI, 0.88-0.91]). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates. CONCLUSIONS aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.
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Affiliation(s)
- Mariam Ali
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Luuk Dekker
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Jasper D Daems
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (J.D.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Erik W van Zwet
- Department of Biomedical Data Sciences (E.W.v.Z., E.W.S.), Leiden University Medical Center, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences (E.W.v.Z., E.W.S.), Leiden University Medical Center, the Netherlands
| | - Martijne H C Duvekot
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., H.K.)
| | - T Truc My Nguyen
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
| | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands (W.M.)
| | - Ruben M van de Wijdeven
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marieke C Visser
- Department of Neurology (M.C.V.)
- Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands (M.C.V.)
| | - Karlijn F de Laat
- Department of Neurology, Haga Hospital, the Hague, the Netherlands (K.F.d.L.)
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands (M.H.C.D., H.K.)
| | - Ido R van den Wijngaard
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands (I.R.v.d.W.)
- University Neurovascular Center Leiden-The Hague, the Netherlands (I.R.v.d.W., N.D.K.)
| | - Diederik W J Dippel
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (J.D.D., M.H.C.D., R.M.v.d.W., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- University Neurovascular Center Leiden-The Hague, the Netherlands (I.R.v.d.W., N.D.K.)
| | - Marieke J H Wermer
- Department of Neurology (Mariam Ali, L.D., I.R.v.d.W., N.D.K., M.J.H.W., T.T.M.N.), Leiden University Medical Center, the Netherlands
- Department of Neurology, University Medical Centre Groningen, University of Groningen, the Netherlands (M.J.H.W.)
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Alkhiri A, Alamri AF, Alharbi AR, Almaghrabi AA, Alansari N, Niaz AA, Alghamdi BA, Sarraj A, Alhazzani A, Al-Ajlan FS. Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis. Eur Stroke J 2024; 9:69-77. [PMID: 37752802 PMCID: PMC10916830 DOI: 10.1177/23969873231201715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Isolated posterior cerebral artery occlusions (iPCAO) were underrepresented in pivotal randomized clinical trial (RCTs) of endovascular thrombectomy (EVT) in ischemic stroke, and the benefit of EVT in this population is still indeterminate. We performed a systematic review and a meta-analysis to compare the safety and efficacy of EVT compared to best medical management (BMM) in patients with iPCAO. METHODS We searched Medline/PubMed, Embase, Web of Science, and the Cochrane databases up to May 2023 for eligible studies reporting outcomes of patients with iPCAO treated with EVT or BMM. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI) using a random-effects model. RESULTS Seven studies involving 2560 patients were included. EVT was associated with significantly higher likelihood of early neurological improvement (OR, 2.31 [95% CI, 1.38-2.91]; p < 0.00001) and visual field normalization (OR, 3.08 [95% CI, 1.76-5.38]; p < 0.0001) compared to BMM. Rates of good functional outcomes (mRS 0-2) were comparable between the two arms (OR, 0.88 [95% CI, 0.70-1.10]; p = 0.26). Symptomatic intracranial hemorrhage (sICH) was comparable between the two groups (OR, 1.94 [95% CI, 0.96-3.93]; p = 0.07). Mortality was also similar between the two groups (OR, 1.36; [95% CI, 0.77-2.42]; p = 0.29). CONCLUSIONS In patients with iPCAO, EVT was associated with visual and early neurological improvement but with a strong trend toward increased sICH. Survival and functional outcomes may be slightly poorer. The role of EVT in iPCAO remains uncertain.
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Affiliation(s)
- Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Aser F Alamri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Ahmed A Almaghrabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Nayef Alansari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulelah A Niaz
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Basil A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Amrou Sarraj
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Adel Alhazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Koneru M, Hoseinyazdi M, Lakhani DA, Greene C, Copeland K, Wang R, Xu R, Luna L, Caplan JM, Dmytriw AA, Guenego A, Heit JJ, Albers GW, Wintermark M, Gonzalez LF, Urrutia VC, Huang J, Nael K, Leigh R, Marsh EB, Hillis AE, Llinas RH, Yedavalli VS. Redefining CT perfusion-based ischemic core estimates for the ghost core in early time window stroke. J Neuroimaging 2024; 34:249-256. [PMID: 38146065 DOI: 10.1111/jon.13180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND AND PURPOSE In large vessel occlusion (LVO) stroke patients, relative cerebral blood flow (rCBF)<30% volume thresholds are commonly used in treatment decisions. In the early time window, nearly infarcted but salvageable tissue volumes may lead to pretreatment overestimates of infarct volume, and thus potentially exclude patients who may otherwise benefit from intervention. Our multisite analysis aims to explore the strength of relationships between widely used pretreatment CT parameters and clinical outcomes for early window stroke patients. METHODS Patients from two sites in a prospective registry were analyzed. Patients with LVOs, presenting within 3 hours of last known well, and who were successfully reperfused were included. Primary short-term neurological outcome was percent National Institutes of Health Stroke Scale (NIHSS) change from admission to discharge. Secondary long-term outcome was 90-day modified Rankin score. Spearman's correlations were performed. Significance was attributed to p-value ≤.05. RESULTS Among 73 patients, median age was 66 (interquartile range 54-76) years. Among all pretreatment imaging parameters, rCBF<30%, rCBF<34%, and rCBF<38% volumes were significantly, inversely correlated with percentage NIHSS change (p<.048). No other parameters significantly correlated with outcomes. CONCLUSIONS Our multisite analysis shows that favorable short-term neurological recovery was significantly correlated with rCBF volumes in the early time window. However, modest strength of correlations provides supportive evidence that the applicability of general ischemic core estimate thresholds in this subpopulation is limited. Our results support future larger-scale efforts to liberalize or reevaluate current rCBF parameter thresholds guiding treatment decisions for early time window stroke patients.
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Affiliation(s)
- Manisha Koneru
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | | | | | - Cynthia Greene
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Richard Wang
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Licia Luna
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Adam A Dmytriw
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adrien Guenego
- Université Libre De Bruxelles Hospital Erasme, Brussels, Belgium
| | - Jeremy J Heit
- Stanford University School of Medicine, Stanford, California, USA
| | - Gregory W Albers
- Stanford University School of Medicine, Stanford, California, USA
| | - Max Wintermark
- University of Texas MD Anderson Center, Houston, Texas, USA
| | | | | | - Judy Huang
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kambiz Nael
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Richard Leigh
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Argye E Hillis
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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50
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Alkhiri A, Al-Ajlan FS. Authors' response to 'Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis'. Eur Stroke J 2024; 9:276. [PMID: 38009692 PMCID: PMC10916824 DOI: 10.1177/23969873231216817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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