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Schwartz I, Boesen ME, Cerchiaro G, Doram C, Edwards BD, Ganesh A, Greenfield J, Jamieson S, Karnik V, Kenney C, Lim R, Menon BK, Mponponsuo K, Rathwell S, Ryckborst KJ, Stewart B, Yaskina M, Metz L, Richer L, Hill MD. Assessing the efficacy and safety of hydroxychloroquine as outpatient treatment of COVID-19: a randomized controlled trial. CMAJ Open 2021; 9:E693-E702. [PMID: 34145052 PMCID: PMC8248582 DOI: 10.9778/cmajo.20210069] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Identification of therapies to prevent severe COVID-19 remains a priority. We sought to determine whether hydroxychloroquine treatment for outpatients with SARS-CoV-2 infection could prevent hospitalization, mechanical ventilation or death. METHODS This randomized controlled trial was conducted in Alberta during the first wave of the COVID-19 pandemic without direct contact with participants. Community-dwelling individuals with confirmed SARS-CoV-2 infection (by reverse transcription polymerase chain reaction [RT-PCR] viral ribonucleic acid test) within the previous 4 days, and symptom onset within the previous 12 days, were randomly assigned to oral hydroxychloroquine or matching placebo for 5 days. Enrolment began Apr. 15, 2020. The primary outcome was the composite of hospitalization, invasive mechanical ventilation or death within 30 days. Secondary outcomes included symptom duration and disposition at 30 days. Safety outcomes, such as serious adverse events and mortality, were also ascertained. Outcomes were determined by telephone follow-up and administrative data. RESULTS Among 4919 individuals with a positive RT-PCR test, 148 (10.2% of a planned 1446 patients) were randomly assigned, 111 to hydroxychloroquine and 37 to placebo. Of the 148 participants, 24 (16.2%) did not start the study drug. Four participants in the hydroxychloroquine group met the primary outcome (4 hospitalizations, 0 mechanical ventilation, 4 survived to 30 days) and none in the placebo group. Hydroxychloroquine did not reduce symptom duration (hazard ratio 0.77, 95% confidence interval 0.49-1.21). Recruitment was paused on May 22, 2020, when a since-retracted publication raised concerns about the safety of hydroxychloroquine for hospitalized patients with COVID-19. Although we had not identified concerns in a safety review, enrolment was slower than expected among those eligible for the study, and cases within the community were decreasing. Recruitment goals were deemed to be unattainable and the trial was not resumed, resulting in a study underpowered to assess the effect of treatment with hydroxychloroquine and safety. INTERPRETATION There was no evidence that hydroxychloroquine reduced symptom duration or prevented severe outcomes among outpatients with proven COVID-19, but the early termination of our study meant that it was underpowered. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT04329611.
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Affiliation(s)
- Ilan Schwartz
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Mari E Boesen
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Graziela Cerchiaro
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Craig Doram
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Brett D Edwards
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Aravind Ganesh
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Jamie Greenfield
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Scott Jamieson
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Vikram Karnik
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Carol Kenney
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Rachel Lim
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Bijoy K Menon
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Kwadwo Mponponsuo
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sarah Rathwell
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Karla J Ryckborst
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Breanne Stewart
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Maryna Yaskina
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Luanne Metz
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Lawrence Richer
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Michael D Hill
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.
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Hill MD, Goyal M, Menon BK, Nogueira RG, McTaggart RA, Demchuk AM, Poppe AY, Buck BH, Field TS, Dowlatshahi D, van Adel BA, Swartz RH, Shah RA, Sauvageau E, Zerna C, Ospel JM, Joshi M, Almekhlafi MA, Ryckborst KJ, Lowerison MW, Heard K, Garman D, Haussen D, Cutting SM, Coutts SB, Roy D, Rempel JL, Rohr AC, Iancu D, Sahlas DJ, Yu AYX, Devlin TG, Hanel RA, Puetz V, Silver FL, Campbell BCV, Chapot R, Teitelbaum J, Mandzia JL, Kleinig TJ, Turkel-Parrella D, Heck D, Kelly ME, Bharatha A, Bang OY, Jadhav A, Gupta R, Frei DF, Tarpley JW, McDougall CG, Holmin S, Rha JH, Puri AS, Camden MC, Thomalla G, Choe H, Phillips SJ, Schindler JL, Thornton J, Nagel S, Heo JH, Sohn SI, Psychogios MN, Budzik RF, Starkman S, Martin CO, Burns PA, Murphy S, Lopez GA, English J, Tymianski M. Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial. Lancet 2020; 395:878-887. [PMID: 32087818 DOI: 10.1016/s0140-6736(20)30258-0] [Citation(s) in RCA: 349] [Impact Index Per Article: 87.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Nerinetide, an eicosapeptide that interferes with post-synaptic density protein 95, is a neuroprotectant that is effective in preclinical stroke models of ischaemia-reperfusion. In this trial, we assessed the efficacy and safety of nerinetide in human ischaemia-reperfusion that occurs with rapid endovascular thrombectomy in patients who had an acute ischaemic stroke. METHODS For this multicentre, double-blind, randomised, placebo-controlled study done in 48 acute care hospitals in eight countries, we enrolled patients with acute ischaemic stroke due to large vessel occlusion within a 12 h treatment window. Eligible patients were aged 18 years or older with a disabling ischaemic stroke at the time of randomisation, had been functioning independently in the community before the stroke, had an Alberta Stroke Program Early CT Score (ASPECTS) greater than 4, and vascular imaging showing moderate-to-good collateral filling, as determined by multiphase CT angiography. Patients were randomly assigned (1:1) to receive intravenous nerinetide in a single dose of 2·6 mg/kg, up to a maximum dose of 270 mg, on the basis of estimated or actual weight (if known) or saline placebo by use of a real-time, dynamic, internet-based, stratified randomised minimisation procedure. Patients were stratified by intravenous alteplase treatment and declared endovascular device choice. All trial personnel and patients were masked to sequence and treatment allocation. All patients underwent endovascular thrombectomy and received alteplase in usual care when indicated. The primary outcome was a favourable functional outcome 90 days after randomisation, defined as a modified Rankin Scale (mRS) score of 0-2. Secondary outcomes were measures of neurological disability, functional independence in activities of daily living, excellent functional outcome (mRS 0-1), and mortality. The analysis was done in the intention-to-treat population and adjusted for age, sex, baseline National Institutes of Health Stroke Scale score, ASPECTS, occlusion location, site, alteplase use, and declared first device. The safety population included all patients who received any amount of study drug. This trial is registered with ClinicalTrials.gov, NCT02930018. FINDINGS Between March 1, 2017, and Aug 12, 2019, 1105 patients were randomly assigned to receive nerinetide (n=549) or placebo (n=556). 337 (61·4%) of 549 patients with nerinetide and 329 (59·2%) of 556 with placebo achieved an mRS score of 0-2 at 90 days (adjusted risk ratio 1·04, 95% CI 0·96-1·14; p=0·35). Secondary outcomes were similar between groups. We observed evidence of treatment effect modification resulting in inhibition of treatment effect in patients receiving alteplase. Serious adverse events occurred equally between groups. INTERPRETATION Nerinetide did not improve the proportion of patients achieving good clinical outcomes after endovascular thrombectomy compared with patients receiving placebo. FUNDING Canadian Institutes for Health Research, Alberta Innovates, and NoNO.
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Affiliation(s)
- Michael D Hill
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.
| | - Mayank Goyal
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Raul G Nogueira
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Ryan A McTaggart
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Andrew M Demchuk
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Alexandre Y Poppe
- Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Brian H Buck
- University of Alberta Hospital, Edmonton, AB, Canada
| | | | | | | | - Richard H Swartz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON, Canada
| | | | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, FL, USA
| | - Charlotte Zerna
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Johanna M Ospel
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Manish Joshi
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | | | - Karla J Ryckborst
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Mark W Lowerison
- Clinical Research Unit, University of Calgary, Calgary, AB, Canada
| | | | | | - Diogo Haussen
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Shawna M Cutting
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Shelagh B Coutts
- Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Daniel Roy
- Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Axel Cr Rohr
- University of British Columbia, Vancouver, BC, Canada
| | - Daniela Iancu
- Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | | | - Amy Y X Yu
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON, Canada
| | | | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, FL, USA
| | - Volker Puetz
- University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden Neurovascular Center, Dresden, Germany
| | - Frank L Silver
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Bruce C V Campbell
- The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - René Chapot
- Department of Neuroradiology and Endovascular Therapy, Alfred Krupp Krankenhaus Hospital, Essen, Germany
| | - Jeanne Teitelbaum
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | | | | | | | - Donald Heck
- Forsyth Medical Center, Winston-Salem, NC, USA
| | - Michael E Kelly
- Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
| | - Aditya Bharatha
- St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Oh Young Bang
- Samsung Medical Center, Departments of Neurology and Radiology, Sungkyunkwan University, Seoul, South Korea
| | - Ashutosh Jadhav
- University of Pittsburgh Medical Centre, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rishi Gupta
- Wellstar Health Systems, Kennestone Hospital, Marietta, GA, USA
| | - Donald F Frei
- Swedish Medical Center, Colorado Neurological Institute, Denver, CO, USA
| | - Jason W Tarpley
- Providence Little Company of Mary Medical Center, Providence Saint John's Health Center and The Pacific Neuroscience Institute, Torrance, CA, USA
| | | | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Departments of Neuroradiology and Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Joung-Ho Rha
- Inha University Hospital Neurology, Incheon, South Korea
| | - Ajit S Puri
- University of Massachusetts Medical Center, University of Massachusetts, Worcester, MA, USA
| | - Marie-Christine Camden
- Enfant-Jésus Hospital, Centre Hospitalier Universitaire de Québec, Laval University, Québec City, QC, Canada
| | - Götz Thomalla
- Department of Neurology and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hana Choe
- Neurosciences Institute, Abington Jefferson Hospital, Philadelphia, PA, USA
| | - Stephen J Phillips
- Queen Elizabeth II Health Science Centre, Dalhousie University, Halifax, NS, Canada
| | | | | | - Simon Nagel
- University Hospital Heidelberg, Heidelberg, Germany
| | - Ji Hoe Heo
- Yonsei University College of Medicine, Seoul, South Korea
| | - Sung-Il Sohn
- Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea
| | | | - Ronald F Budzik
- Ohio Health, Riverside Methodist Hospital, Columbus, OH, USA
| | - Sidney Starkman
- UCLA Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, CA, USA
| | | | | | - Seán Murphy
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - George A Lopez
- Rush University Medical Center, Rush University, Chicago, IL, USA
| | - Joey English
- California Pacific Medical Center, Sutter Health, San Francisco, CA, USA
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Chau D, Garman D, Adams C, Zhang Y, Rizwan A, Ryckborst KJ, Goyal M, Hill MD, Christenson J, Tymianski M. Abstract TP394: Senior Clinical Project Leader. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
FRONTIER (NCT02315443) and ESCAPE-NA1 (NCT02930018) are two pivotal trials investigating the safety and efficacy of the neuroprotectant NA-1 in acute ischemic stroke (AIS). NA-1 administration is weight-based (2.6mg/Kg), requiring the rapid estimation of body weight by paramedics in the field (FRONTIER) and by hospital staff upon ED arrival (ESCAPE-NA1). Alteplase, which is administered after hospital arrival, also requires weight-based dosing. Here we evaluated the accuracy of the body weight estimated by paramedics and by hospital staff prior to administering study drug (NA-1 or placebo) as compared to the actual subject weight collected using in-hospital scales during the subsequent in-hospital stay.
Methodology:
In both these studies, FRONTIER and ESCAPE-NA1, paramedics in the field and Hospital staff will be determining weight by first asking the subject, second asking a family member or third by estimation. Subsequently, in each trial, in-hospital scales are used during the subject’s admission to measure body weight accurately. The subject’s actual weight will be measured in hospital using standard hospital scales (i.e., stand up or in-bed scales if the subject is not ambulatory), as soon as possible, but within five days. Data were obtained from the trial database.
Results:
As of August 1
st
2018, 264 subjects were enrolled in FRONTIER of which 206 had all body weight data available, and 444 subjects were enrolled in ESCAPE-NA1 of which 218 had all body weight data available. As compared with in-hospital scales, paramedics over estimated patient weight by an average of 2.57 kg (SD = 6.94 P< 0.001). In-hospital staff under estimated patient weight by an average of 1.82kg (SD = 8.93 P=0.003). The difference is statistically significant but not clinically meaningful. Overall, the weight estimated by paramedics and by hospital staff was 93% accurate, when compared to the actual weight collected.
Conclusion:
Both paramedics and hospital staff were mostly accurate when estimating patient weight in the acute care settings of FRONTIER and ESCAPE-NA1. This suggests that when time is of the essence, weight may be estimated effectively for the purpose of administering stroke drugs.
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Affiliation(s)
- Davis Chau
- Clinical Development, NoNO Inc., Toronto, Canada
| | | | | | | | | | | | - Mayank Goyal
- Radiology and Clinical Neurosciences, Univ of Calgary, Calgary, Canada
| | | | - Jim Christenson
- Emergency Medicine, Univ of British Columbia, Vancouver, Canada
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M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D. Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 2018; 17:895-904. [DOI: 10.1016/s1474-4422(18)30242-4] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022]
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N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol 2018; 17:47-53. [DOI: 10.1016/s1474-4422(17)30407-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/05/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
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Simpson KN, Simpson AN, Mauldin PD, Palesch YY, Yeatts SD, Kleindorfer D, Tomsick TA, Foster LD, Demchuk AM, Khatri P, Hill MD, Jauch EC, Jovin TG, Yan B, von Kummer R, Molina CA, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson C, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Broderick JP. Observed Cost and Variations in Short Term Cost-Effectiveness of Therapy for Ischemic Stroke in Interventional Management of Stroke (IMS) III. J Am Heart Assoc 2017; 6:JAHA.116.004513. [PMID: 28483774 PMCID: PMC5524059 DOI: 10.1161/jaha.116.004513] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Examination of linked data on patient outcomes and cost of care may help identify areas where stroke care can be improved. We report on the association between variations in stroke severity, patient outcomes, cost, and treatment patterns observed over the acute hospital stay and through the 12‐month follow‐up for subjects receiving endovascular therapy compared to intravenous tissue plasminogen activator alone in the IMS (Interventional Management of Stroke) III Trial. Methods and Results Prospective data collected for a prespecified economic analysis of the trial were used. Data included hospital billing records for the initial stroke admission and subsequent detailed resource use after the acute hospitalization collected at 3, 6, 9, and 12 months. Cost of follow‐up care varied 6‐fold for patients in the lowest (0–1) and highest (20+) National Institutes of Health Stroke Scale category at 5 days, and by modified Rankin Scale at 3 months. The kind of resources used postdischarge also varied between treatment groups. Incremental short‐term cost‐effectiveness ratios varied greatly when treatments were compared for patient subgroups. Patient subgroups predefined by stroke severity had incremental cost‐effectiveness ratios of $97 303/quality‐adjusted life year (severe stroke) and $3 187 805/quality‐adjusted life year (moderately severe stroke). Conclusions Detailed economic and resource utilization data from IMS III provide powerful evidence for the large effect that patient outcome has on the economic value of medical and endovascular reperfusion therapies. These data can be used to inform process improvements for stroke care and to estimate the cost‐effectiveness of endovascular therapy in the US health system for stroke intervention trials. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Registration number: NCT00359424.
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Affiliation(s)
- Kit N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Annie N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Patrick D Mauldin
- Department of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC
| | - Yuko Y Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Dawn Kleindorfer
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Thomas A Tomsick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Lydia D Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Andrew M Demchuk
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Michael D Hill
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Edward C Jauch
- Division of Emergency Medicine, Medical University of South Carolina, Charleston, SC
| | - Tudor G Jovin
- Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Rüdiger von Kummer
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Mayank Goyal
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Wouter J Schonewille
- Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, The Netherlands.,St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Mikael Mazighi
- Department of Neurology and Stroke Center, Lariboisière Hospital, DHU NeuroVasc, Paris, France
| | - Stefan T Engelter
- Neurorehabilitation Unit, Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland.,University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland
| | - Craig Anderson
- George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Judith Spilker
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Janice Carrozzella
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Karla J Ryckborst
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - L Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Joseph P Broderick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
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Kamal N, Smith EE, Menon BK, Eesa M, Ryckborst KJ, Poppe AY, Roy D, Thornton J, Williams D, Casaubon LK, Silver FL, Butcher K, Shuaib A, Rempel JL, Jovin TG, Sapkota BL, Demchuk AM, Goyal M, Hill MD. Improving reperfusion time within the ESCAPE Endovascular Clinical Trial. Eur Stroke J 2016; 2:64-69. [PMID: 31008303 DOI: 10.1177/2396987316681176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/04/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction Endovascular treatment of acute ischemic stroke is more effective when performed quickly. In this report, we describe quality interventions to ensure fast endovascular treatment times in the ESCAPE (Endovascular Treatment for Small Core and Anterior circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times) trial. Methods An "audit and feedback" intervention using webinar and letter was used to improve treatment time over the course of the trial. The time metrics were computed tomography-to-groin-puncture (target < 60 min) and computed tomography-to-first-reperfusion (target < 90 min). Each site was provided with their data for computed tomography-to-groin-puncture and computed tomography-to-first-reperfusion for all their patients that were randomized to the treatment arm, and their median time was compared to the overall median times of all sites in the trial. We assessed for changes in treatment time over the course of the trial. Results There were 165 patients enrolled into the endovascular arm from 22 sites. The computed tomography-to-groin-puncture time dropped from 57 to 47 min (p = 0.14) while computed tomography-to-reperfusion time dropped from 89 to 81 min (p = 0.48). Over the course of the trial, the absolute treatment benefit increased by 7.8% (p < 0.001). Conclusions An "audit and feedback" intervention throughout the conduct of the ESCAPE trial was a feasible way to ensure fast treatment times. Quality improvement processes should continue as standard practice beyond the trial to encourage good patient selection and the best clinical outcomes.
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Affiliation(s)
- Noreen Kamal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Eric E Smith
- Department of Clinical Neurosciences, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Muneer Eesa
- Department of Radiology, Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Canada
| | | | - Alexandre Y Poppe
- CHUM Stroke Program, Department of Neurosciences, Université de Montréal, Canada
| | - Daniel Roy
- CHUM Stroke Program, Department of Neurosciences, Université de Montréal, Canada
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital, Ireland
| | - David Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Ireland
| | - Leanne K Casaubon
- Division of Neurology, University of Toronto, Stroke Program University Health Network, Canada.,TIA and Minor Stroke (TAMS) Unit, Toronto Western Hospital, Canada
| | - Frank L Silver
- Division of Neurology, University of Toronto, Stroke Program University Health Network, Canada
| | | | - Ashfaq Shuaib
- Division of Neurology, University of Alberta, Director Stroke Program, Canada
| | - Jeremy L Rempel
- University of Alberta Hospital, Alberta Health Services, Canada
| | - Tudor G Jovin
- Department of Neurology, University of Pittsburgh, USA
| | | | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
| | - Mayank Goyal
- Department of Radiology, Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Canada
| | - Michael D Hill
- Departments of Clinical Neurosciences, Medicine, Radiology and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada
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Broderick JP, Berkhemer OA, Palesch YY, Dippel DWJ, Foster LD, Roos YBWEM, van der Lugt A, Tomsick TA, Majoie CBLM, van Zwam WH, Demchuk AM, van Oostenbrugge RJ, Khatri P, Lingsma HF, Hill MD, Roozenbeek B, Jauch EC, Jovin TG, Yan B, von Kummer R, Molina CA, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson CS, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Simpson KN. Endovascular Therapy Is Effective and Safe for Patients With Severe Ischemic Stroke: Pooled Analysis of Interventional Management of Stroke III and Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands Data. Stroke 2015; 46:3416-22. [PMID: 26486865 DOI: 10.1161/strokeaha.115.011397] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/08/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We assessed the effect of endovascular treatment in acute ischemic stroke patients with severe neurological deficit (National Institutes of Health Stroke Scale score, ≥20) after a prespecified analysis plan. METHODS The pooled analysis of the Interventional Management of Stroke III (IMS III) and Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trials included participants with an National Institutes of Health Stroke Scale score of ≥20 before intravenous tissue-type plasminogen activator (tPA) treatment (IMS III) or randomization (MR CLEAN) who were treated with intravenous tPA ≤3 hours of stroke onset. Our hypothesis was that participants with severe stroke randomized to endovascular therapy after intravenous tPA would have improved 90-day outcome (distribution of modified Rankin Scale scores), when compared with those who received intravenous tPA alone. RESULTS Among 342 participants in the pooled analysis (194 from IMS III and 148 from MR CLEAN), an ordinal logistic regression model showed that the endovascular group had superior 90-day outcome compared with the intravenous tPA group (adjusted odds ratio, 1.78; 95% confidence interval, 1.20-2.66). In the logistic regression model of the dichotomous outcome (modified Rankin Scale score, 0-2, or functional independence), the endovascular group had superior outcomes (adjusted odds ratio, 1.97; 95% confidence interval, 1.09-3.56). Functional independence (modified Rankin Scale score, ≤2) at 90 days was 25% in the endovascular group when compared with 14% in the intravenous tPA group. CONCLUSIONS Endovascular therapy after intravenous tPA within 3 hours of symptom onset improves functional outcome at 90 days after severe ischemic stroke. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424 (IMS III) and ISRCTN10888758 (MR CLEAN).
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Affiliation(s)
- Joseph P Broderick
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Olvert A Berkhemer
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Yuko Y Palesch
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Diederik W J Dippel
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Lydia D Foster
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Yvo B W E M Roos
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Aad van der Lugt
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Thomas A Tomsick
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Charles B L M Majoie
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Wim H van Zwam
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Andrew M Demchuk
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Robert J van Oostenbrugge
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Pooja Khatri
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Hester F Lingsma
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Michael D Hill
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Bob Roozenbeek
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Edward C Jauch
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Tudor G Jovin
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Bernard Yan
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Rüdiger von Kummer
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Carlos A Molina
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Mayank Goyal
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Wouter J Schonewille
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Mikael Mazighi
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Stefan T Engelter
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Craig S Anderson
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Judith Spilker
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Janice Carrozzella
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Karla J Ryckborst
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - L Scott Janis
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
| | - Kit N Simpson
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH (J.P.B., P.K., J.S., J.C., T.A.T.); Division of Emergency Medicine (E.C.J.), Department of Public Health Sciences (Y.Y.P., L.D.F.), and Department of Healthcare Management and Leadership (K.N.S.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H., M.G., K.J.R.); the Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands (W.J.S.); St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris, France (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); the George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.S.A.); and the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.); the Department of Radiology (O.A.B., C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.W.J.D., B.R.), Radiology (A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands; and Department of Radiology (W.H.v.Z.) and N
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Palesch YY, Yeatts SD, Tomsick TA, Foster LD, Demchuk AM, Khatri P, Hill MD, Jauch EC, Jovin TG, Yan B, von Kummer R, Molina CA, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson C, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Simpson A, Simpson KN, Broderick JP. Twelve-Month Clinical and Quality-of-Life Outcomes in the Interventional Management of Stroke III Trial. Stroke 2015; 46:1321-7. [PMID: 25858239 DOI: 10.1161/strokeaha.115.009180] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/04/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Randomized trials have indicated a benefit for endovascular therapy in appropriately selected stroke patients at 3 months, but data regarding outcomes at 12 months are currently lacking. METHODS We compared functional and quality-of-life outcomes at 12 months overall and by stroke severity in stroke patients treated with intravenous tissue-type plasminogen activator followed by endovascular treatment as compared with intravenous tissue-type plasminogen activator alone in the Interventional Management of Stroke III Trial. The key outcome measures were a modified Rankin Scale score ≤2 (functional independence) and the Euro-QoL EQ-5D, a health-related quality-of-life measure. RESULTS 656 subjects with moderate-to-severe stroke (National Institutes of Health Stroke Scale ≥8) were enrolled at 58 centers in the United States (41 sites), Canada (7), Australia (4), and Europe (6). There was an interaction between treatment group and stroke severity in the repeated measures analysis of modified Rankin Scale ≤2 outcome (P=0.039). In the 204 participants with severe stroke (National Institutes of Health Stroke Scale ≥20), a greater proportion of the endovascular group had a modified Rankin Scale ≤2 (32.5%) at 12 months as compared with the intravenous tissue-type plasminogen activator group (18.6%, P=0.037); no difference was seen for the 452 participants with moderately severe strokes (55.6% versus 57.7%). In participants with severe stroke, the endovascular group had 35.2 (95% confidence interval: 2.1, 73.3) more quality-adjusted-days over 12 months as compared with intravenous tissue-type plasminogen activator alone. CONCLUSIONS Endovascular therapy improves functional outcome and health-related quality-of-life at 12 months after severe ischemic stroke. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424.
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Affiliation(s)
- Yuko Y Palesch
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Sharon D Yeatts
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Thomas A Tomsick
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Lydia D Foster
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Andrew M Demchuk
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Pooja Khatri
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Michael D Hill
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Edward C Jauch
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Tudor G Jovin
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Bernard Yan
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Rüdiger von Kummer
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Carlos A Molina
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Mayank Goyal
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Wouter J Schonewille
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Mikael Mazighi
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Stefan T Engelter
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Craig Anderson
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Judith Spilker
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Janice Carrozzella
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Karla J Ryckborst
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - L Scott Janis
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Annie Simpson
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Kit N Simpson
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Joseph P Broderick
- From the Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati (J.P.B., P.K., J.S., J.C., T.A.T.); Department of Public Health Sciences (Y.Y.P., S.D.Y., L.D.F., A.S., K.N.S.) and Division of Emergency Medicine (E.C.J.), Medical University of South Carolina, Charleston; Calgary Stroke Program, Seaman Family MR Research Centre, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.D.H., M.G., K.J.R.); Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh (T.G.J.); Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia (B.Y.); Department of Neuroradiology, Dresden University Stroke Center, University Hospital, Dresden, Germany (R.v.K.); Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.); Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, the Netherlands, and the St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.); Department of Neurology and Stroke Center, Lariboisière Hospital, Paris (M.M.); Department of Neurology, Basel University Hospital, Basel, Switzerland (S.T.E.); George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney (C.A.); and National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.).
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Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372:1019-30. [PMID: 25671798 DOI: 10.1056/nejmoa1414905] [Citation(s) in RCA: 4198] [Impact Index Per Article: 466.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. METHODS We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis). RESULTS The trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P<0.001). The primary outcome favored the intervention (common odds ratio, 2.6; 95% confidence interval, 1.7 to 3.8; P<0.001), and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group; P=0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P=0.75). CONCLUSIONS Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality. (Funded by Covidien and others; ESCAPE ClinicalTrials.gov number, NCT01778335.).
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Affiliation(s)
- Mayank Goyal
- The authors' affiliations are listed in the Appendix
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11
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Demchuk AM, Goyal M, Menon BK, Eesa M, Ryckborst KJ, Kamal N, Patil S, Mishra S, Almekhlafi M, Randhawa PA, Roy D, Willinsky R, Montanera W, Silver FL, Shuaib A, Rempel J, Jovin T, Frei D, Sapkota B, Thornton JM, Poppe A, Tampieri D, Lum C, Weill A, Sajobi TT, Hill MD. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke 2014; 10:429-38. [PMID: 25546514 DOI: 10.1111/ijs.12424] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 11/12/2014] [Indexed: 01/21/2023]
Abstract
ESCAPE is a prospective, multicenter, randomized clinical trial that will enroll subjects with the following main inclusion criteria: less than 12 h from symptom onset, age > 18, baseline NIHSS >5, ASPECTS score of >5 and CTA evidence of carotid T/L or M1 segment MCA occlusion, and at least moderate collaterals by CTA. The trial will determine if endovascular treatment will result in higher rates of favorable outcome compared with standard medical therapy alone. Patient populations that are eligible include those receiving IV tPA, tPA ineligible and unwitnessed onset or wake up strokes with 12 h of last seen normal. The primary end-point, based on intention-to-treat criteria is the distribution of modified Rankin Scale scores at 90 days assessed using a proportional odds model. The projected maximum sample size is 500 subjects. Randomization is stratified under a minimization process using age, gender, baseline NIHSS, baseline ASPECTS (8-10 vs. 6-7), IV tPA treatment and occlusion location (ICA vs. MCA) as covariates. The study will have one formal interim analysis after 300 subjects have been accrued. Secondary end-points at 90 days include the following: mRS 0-1; mRS 0-2; Barthel 95-100, EuroQOL and a cognitive battery. Safety outcomes are symptomatic ICH, major bleeding, contrast nephropathy, total radiation dose, malignant MCA infarction, hemicraniectomy and mortality at 90 days.
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Affiliation(s)
- Andrew M Demchuk
- Departments of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Ginsberg MD, Hill MD, Moy CS, Barsan WG, Tamariz D, Ryckborst KJ. Abstract T P49: Improving Outcome of Placebo- but not Albumin-Treated Subjects Over the Course of the ALIAS Part 2 Multicenter Trial: Differential Influence of Thrombolytic Therapy. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.tp49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the ALIAS2 Trial, 841 subjects were randomized 1:1 to treatment with either 25% albumin (ALB, 2 g/kg) or normal saline within 5 hours of stroke onset, and the primary outcome (NIHSS 0-1 and/or modified Rankin scale 0-1) was assessed at 90 days. While overall outcomes did not differ by treatment (44% for both groups), we observed a steadily improving favorable rate in the saline-placebo arm but not in the ALB arm over the trial’s 3.5 year course. This was further analyzed here.
Methods and Findings:
Logistic regression confirmed a significant randomization-order x treatment interaction (p<0.001). Thus, at the first pre-specified interim analysis of N=275 subjects, favorable outcome was seen in 44.8% with ALB but only 30.3% with saline (relative benefit 1.48, p=0.0028), while at the second interim analysis of N=550 subjects, the saline rate had risen to 37.5% while the ALB rate remained steady at 44.6% (relative benefit 1.21, p=0.0176). This trend-over-time in saline subjects was highly significant (Jonckheere-Terpstra (J-T) test, p=0.001; Pearson coefficient r=0.792), but there was no such trend in ALB subjects (J-T p=1.000). Simulation analysis confirmed that the saline trend could not have arisen by chance (p=0.0007). Importantly, intravenous tPA use also increased significantly during the trial in both ALB and saline subjects (initial rate 74%, final rate 95%, p<0.0001). Separate logistic regression analyses revealed a highly significant effect of IV tPA use on outcome in saline subjects (odds ratio 2.8, 95% CI 1.5-5.3, p=0.001) but only a marginal effect in ALB subjects (odds ratio 1.7, p=0.06).
Conclusion:
ALB treatment appears to have conferred a stable (and desirable) therapeutic “ceiling effect” throughout the trial (in the absence of significant toxicity), while saline subjects (who were unable to benefit from ALB) were susceptible to improved outcome from increasing tPA use as the trial progressed.
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Affiliation(s)
| | - Michael D Hill
- Clinical Neurosciences, Univ of Calgary, Calgary, Canada
| | - Claudia S Moy
- Office of Clinical Rsch, National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | | | - Diego Tamariz
- Neurology, Univ of Miami Miller Sch of Medicine, Miami, FL
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Ginsberg MD, Palesch YY, Hill MD, Martin RH, Moy CS, Barsan WG, Waldman BD, Tamariz D, Ryckborst KJ. High-dose albumin treatment for acute ischaemic stroke (ALIAS) Part 2: a randomised, double-blind, phase 3, placebo-controlled trial. Lancet Neurol 2013; 12:1049-58. [PMID: 24076337 DOI: 10.1016/s1474-4422(13)70223-0] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND In animal models of ischaemic stroke, 25% albumin reduced brain infarction and improved neurobehavioural outcome. In a pilot clinical trial, albumin doses as high as 2 g/kg were safely tolerated. We aimed to assess whether albumin given within 5 h of the onset of acute ischaemic stroke increased the proportion of patients with a favourable outcome. METHODS We did a randomised, double-blind, parallel-group, phase 3, placebo-controlled trial between Feb 27, 2009, and Sept 10, 2012, at 69 sites in the USA, 13 sites in Canada, two sites in Finland, and five sites in Israel. Patients aged 18-83 years with ischaemic (ie, non-haemorrhagic) stroke with a baseline National Institutes of Health stroke scale (NIHSS) score of 6 or more who could be treated within 5 h of onset were randomly assigned (1:1), via a central web-based randomisation process with a biased coin minimisation approach, to receive 25% albumin (2 g [8 mL] per kg; maximum dose 750 mL) or the equivalent volume of isotonic saline. All study personnel and participants were masked to the identity of the study drug. The primary endpoint was favourable outcome, defined as either a modified Rankin scale score of 0 or 1, or an NIHSS score of 0 or 1, or both, at 90 days. Analysis was by intention to treat. Thrombolytic therapies were permitted. This trial is registered with ClinicalTrials.gov, number NCT00235495. FINDINGS 422 participants were randomly assigned to receive albumin and 419 to receive saline. On Sept 12, 2012, the trial was stopped early for futility (n=841). The primary outcome did not differ between patients in the albumin group and those in the saline group (186 [44%] vs 185 [44%]; risk ratio 0·96, 95% CI 0·84-1·10, adjusted for baseline NIHSS score and thrombolysis stratum). Mild-to-moderate pulmonary oedema was more common in patients given albumin than in those given saline (54 [13%] of 412 vs 5 [1%] of 412 patients); symptomatic intracranial haemorrhage within 24 h was also more common in patients in the albumin group than in the placebo group (17 [4%] of 415 vs 7 [2%] of 414 patients). Although the rate of favourable outcome in patients given albumin remained consistent at 44-45% over the course of the trial, the cumulative rate of favourable outcome in patients given saline rose steadily from 31% to 44%. INTERPRETATION Our findings show no clinical benefit of 25% albumin in patients with ischaemic stroke; however, they should not discourage further efforts to identify effective strategies to protect the ischaemic brain, especially because of preclinical literature showing convincing proof-of-principle for the possibility of this outcome. FUNDING National Institute of Neurological Disorders and Stroke, US National Institutes of Health; and Baxter Healthcare Corporation.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.
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Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, Jauch EC, Jovin TG, Yan B, Silver FL, von Kummer R, Molina CA, Demaerschalk BM, Budzik R, Clark WM, Zaidat OO, Malisch TW, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson C, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Martin RH, Foster LD, Tomsick TA. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368:893-903. [PMID: 23390923 PMCID: PMC3651875 DOI: 10.1056/nejmoa1214300] [Citation(s) in RCA: 1336] [Impact Index Per Article: 121.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endovascular therapy is increasingly used after the administration of intravenous tissue plasminogen activator (t-PA) for patients with moderate-to-severe acute ischemic stroke, but whether a combined approach is more effective than intravenous t-PA alone is uncertain. METHODS We randomly assigned eligible patients who had received intravenous t-PA within 3 hours after symptom onset to receive additional endovascular therapy or intravenous t-PA alone, in a 2:1 ratio. The primary outcome measure was a modified Rankin scale score of 2 or less (indicating functional independence) at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). RESULTS The study was stopped early because of futility after 656 participants had undergone randomization (434 patients to endovascular therapy and 222 to intravenous t-PA alone). The proportion of participants with a modified Rankin score of 2 or less at 90 days did not differ significantly according to treatment (40.8% with endovascular therapy and 38.7% with intravenous t-PA; absolute adjusted difference, 1.5 percentage points; 95% confidence interval [CI], -6.1 to 9.1, with adjustment for the National Institutes of Health Stroke Scale [NIHSS] score [8-19, indicating moderately severe stroke, or ≥20, indicating severe stroke]), nor were there significant differences for the predefined subgroups of patients with an NIHSS score of 20 or higher (6.8 percentage points; 95% CI, -4.4 to 18.1) and those with a score of 19 or lower (-1.0 percentage point; 95% CI, -10.8 to 8.8). Findings in the endovascular-therapy and intravenous t-PA groups were similar for mortality at 90 days (19.1% and 21.6%, respectively; P=0.52) and the proportion of patients with symptomatic intracerebral hemorrhage within 30 hours after initiation of t-PA (6.2% and 5.9%, respectively; P=0.83). CONCLUSIONS The trial showed similar safety outcomes and no significant difference in functional independence with endovascular therapy after intravenous t-PA, as compared with intravenous t-PA alone. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT00359424.).
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Affiliation(s)
- Joseph P Broderick
- Department of Neurology, University of Cincinnati Neuroscience Institute, University of Cincinnati Academic Health Center, Cincinnati, OH 45267-0525, USA.
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Hill MD, Martin RH, Palesch YY, Tamariz D, Waldman BD, Ryckborst KJ, Moy CS, Barsan WG, Ginsberg MD. The Albumin in Acute Stroke Part 1 Trial: an exploratory efficacy analysis. Stroke 2011; 42:1621-5. [PMID: 21546491 DOI: 10.1161/strokeaha.110.610980] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Albumin in Acute Stroke (ALIAS) Part 2 Trial is directly testing whether 2 g/kg of 25% human albumin (ALB) administered intravenously within 5 hours of ischemic stroke onset results in improved clinical outcome. Recruitment into Part 1 of the ALIAS Trial was halted for safety reasons. ALIAS Part 2 is a new, reformulated trial with more-stringent exclusion criteria. Our aim was to explore the efficacy of ALB in the ALIAS Part 1 data and to assess the statistical assumptions underlying the ALIAS Part 2 Trial. METHODS ALIAS is a multicenter, blinded, randomized controlled trial. Data on 434 subjects, comprising the ALIAS Part 1 subjects, were analyzed. We examined both the thrombolysis and nonthrombolysis cohorts combined and separately in a "target population" by excluding subjects who would not have been eligible for the ALIAS Part 2 Trial; the latter comprised patients >83 years of age, those with elevated baseline troponin values, and those with in-hospital stroke. We examined the differences in the primary composite outcome, defined as a modified Rankin Scale score of 0 to 1 and/or a National Institutes of Health Stroke Scale score of 0 to 1 at 90 days after randomization. RESULTS In the combined thrombolysis plus nonthrombolysis cohorts of the target population, 44.7% of subjects in the ALB group had a favorable outcome compared with 36.0% in the saline group (absolute effect size=8.7%; 95% CI, -2.2% to 19.5%). Among thrombolyzed subjects of the target population, 46.7% had a favorable outcome in the ALB group compared with 36.6% in the saline group (absolute effect size=10.1%; 95% CI, -2.0% to 20.0%). CONCLUSIONS Preliminary results from the ALIAS Part 1 suggest a trend toward a favorable primary outcome in subjects treated with ALB and support the validity of the statistical assumptions that underlie the ALIAS Part 2 Trial. The ALIAS Part 2 Trial will confirm or refute these results. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov/ALIAS. Unique identifier: NCT00235495.
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Affiliation(s)
- Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Foothills Hospital, Room 1242A, 1403 29th St. NW, Calgary, Alberta, T2N 2T9, Canada.
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Cramer SC, Fitzpatrick C, Warren M, Hill MD, Brown D, Whitaker L, Ryckborst KJ, Plon L. The beta-hCG+erythropoietin in acute stroke (BETAS) study: a 3-center, single-dose, open-label, noncontrolled, phase IIa safety trial. Stroke 2010; 41:927-31. [PMID: 20203320 DOI: 10.1161/strokeaha.109.574343] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Animal data suggest the use of beta-human chorionic gonadotropin followed by erythropoietin to promote brain repair after stroke. The current study directly translated these results by evaluating safety of this sequential growth factor therapy through a 3-center, single-dose, open-label, noncontrolled, Phase IIa trial. METHODS Patients with ischemic stroke 24 to 48 hours old and National Institutes of Health Stroke Scale score of 6 to 24 started a 9-day course of beta-human chorionic gonadotropin (once daily on Days 1, 3, and 5 of study participation) followed by erythropoietin (once daily on Days 7, 8, and 9 of study participation). This study also evaluated performance of serially measured domain-specific end points. RESULTS A total of 15 patients were enrolled. Two deaths occurred, neither related to study medications. No safety concerns were noted among clinical or laboratory measures, including screening for deep vein thrombosis and serial measures of serum hemoglobin. In several instances, domain-specific end points provided greater insight into impairments as compared with global outcome measures. CONCLUSIONS Results support the safety of this sequential, 2-growth factor therapy initiated 24 to 48 hours after stroke onset.
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Affiliation(s)
- Steven C Cramer
- University of California, Irvine Medical Center, 101 The City Drive South, Building 53, Room 203, Orange, CA 92868-4280, USA.
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Khatri P, Hill MD, Palesch YY, Spilker J, Jauch EC, Carrozzella JA, Demchuk AM, Martin R, Mauldin P, Dillon C, Ryckborst KJ, Janis S, Tomsick TA, Broderick JP. Methodology of the Interventional Management of Stroke III Trial. Int J Stroke 2008; 3:130-7. [PMID: 18706007 DOI: 10.1111/j.1747-4949.2008.00151.x] [Citation(s) in RCA: 214] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE The Interventional Management of Stroke (IMS) I and II pilot trials demonstrated that the combined intravenous (i.v.) and intraarterial (i.a.) approach to recanalization may be more effective than standard i.v. rt-PA (Activase) alone for moderate-to-large National Institutes of Health Stroke Scale (NIHSS>or=10) strokes, and with a similar safety profile. AIMS The primary objective of this NIH-funded, Phase III, randomized, multicenter, open-label clinical trial is to determine whether a combined i.v./i.a. approach to recanalization is superior to standard i.v. rt-PA alone when initiated within 3 h of acute ischemic stroke onset. The IMS III trial will develop and maintain a network of interventional centers to test the safety, feasibility, and potential efficacy of new FDA-approved catheter devices as part of a combined i.v./i.a. approach to recanalization as the IMS III study progresses. A secondary objective of the IMS III trial is to determine the cost-effectiveness of the combined i.v./i.a. approach as compared with standard i.v. rt-PA. Trial enrollment began in July of 2006. DESIGN A projected 900 subjects with moderate-to-large (NIHSS>or=10) ischemic strokes between ages 18 and 80 will be enrolled over the next 5 years at 40-plus centers in the United States and Canada. Patients must have i.v. treatment initiated within 3 h of stroke onset in both arms. Subjects will be randomized in a 2 : 1 ratio with more subjects enrolled in the combined i.v./i.a. group. The i.v. rt-PA alone group will receive the standard full dose [0.9 mg/kg, 90 mg maximum (10% as bolus)] of rt-PA intravenously over an hour. The combined i.v./i.a. group will receive a lower dose of i.v. rt-PA ( approximately 0.6 mg/kg, 60 mg maximum) over 40 min, followed by immediate angiography. If a treatable thrombus is not demonstrated, no i.a. therapy will be administered. If an appropriate thrombus is identified, treatment will continue with either the Concentric Merci thrombus-removal device, infusion of rt-PA and delivery of low-intensity ultrasound at the site of the occlusion via the EKOS Micro-Infusion Catheter, or infusion of rt-PA via a standard microcatheter. If i.a. rt-Pa therapy is the chosen strategy, a maximum of 22 mg of i.a. rt-PA may be given. The choice of i.a. strategy will be made by the treating neurointerventionalist. The i.a. treatment must begin within 5 h and be completed within 7 h of stroke onset. STUDY OUTCOMES The primary outcome measure is a favorable clinical outcome, defined as a modified Rankin Scale Score of 0-2 at 3 months. The primary safety measure is mortality at 3 months and symptomatic ICH within the 24 h of randomization.
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Affiliation(s)
- Pooja Khatri
- Department of Neurology, University of Cincinnati, 231 Albert Sabin Way ML 0525, Cincinnati, OH 45267-0525, USA.
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Hill MD, Moy CS, Palesch YY, Martin R, Dillon CR, Waldman BD, Patterson L, Mendez IM, Ryckborst KJ, Tamariz D, Ginsberg MD. The albumin in acute stroke trial (ALIAS); design and methodology. Int J Stroke 2008; 2:214-9. [PMID: 18705947 DOI: 10.1111/j.1747-4949.2007.00143.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Stroke is a serious global illness. Human albumin has emerged as a putative therapy for ischaemic stroke based on strong evidence from animal models. Following confirmation of the safety and feasibility of high-dose albumin treatment for acute ischaemic stroke in a pilot study, the Albumin in Acute Stroke trial, a phase 3 randomised, double-blinded, placebo-controlled clinical trial was initiated to evaluate the efficacy of high-dose albumin compared to saline control within 5 h of ischaemic stroke onset. METHODS The trial will enrol 1800 patients in two cohorts--a thrombolytic and a nonthrombolytic arm. High-dose (2 g/kg) human albumin will be administered in a 2-h straight intravenous infusion to ischaemic stroke patients, within 5 h of symptom onset. The primary outcome will be an NIH stroke scale score of 0-1 or a modified Rankin scale score of 0-1 at 90 days. Safety outcomes will include the incidence of congestive heart failure after study-drug administration. RESULTS Enrolment opened at 40 sites in August 2006; new sites continue to be added. Recruitment is ongoing and is projected to be completed by 2010. CONCLUSIONS The trial will continue through 2010. The study is proceeding as planned.
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Affiliation(s)
- Michael D Hill
- Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
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Kennedy J, Hill MD, Ryckborst KJ, Eliasziw M, Demchuk AM, Buchan AM. Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial. Lancet Neurol 2007; 6:961-9. [PMID: 17931979 DOI: 10.1016/s1474-4422(07)70250-8] [Citation(s) in RCA: 357] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with transient ischaemic attack (TIA) or minor stroke are at high immediate risk of stroke. The optimum early treatment options for these patients are not known. METHODS Within 24 h of symptom onset, we randomly assigned, in a factorial design, 392 patients with TIA or minor stroke to clopidogrel (300 mg loading dose then 75 mg daily; 198 patients) or placebo (194 patients), and simvastatin (40 mg daily; 199 patients) or placebo (193 patients). All patients were also given aspirin and were followed for 90 days. Descriptive analyses were done by intention to treat. The primary outcome was total stroke (ischaemic and haemorrhagic) within 90 days. Safety outcomes included haemorrhage related to clopidogrel and myositis related to simvastatin. This study is registered as an International Standard Randomised Controlled Trial (number 35624812) and with ClinicalTrials.gov (NCT00109382). FINDINGS The median time to stroke outcome was 1 day (range 0-62 days). The trial was stopped early due to a failure to recruit patients at the prespecified minimum enrolment rate because of increased use of statins. 14 (7.1%) patients on clopidogrel had a stroke within 90 days compared with 21 (10.8%) patients on placebo (risk ratio 0.7 [95% CI 0.3-1.2]; absolute risk reduction -3.8% [95% CI -9.4 to 1.9]; p=0.19). 21 (10.6%) patients on simvastatin had a stroke within 90 days compared with 14 (7.3%) patients on placebo (risk ratio 1.3 [0.7-2.4]; absolute risk increase 3.3% [-2.3 to 8.9]; p=0.25). The interaction between clopidogrel and simvastatin was not significant (p=0.64). Two patients on clopidogrel had intracranial haemorrhage compared with none on placebo (absolute risk increase 1.0% [-0.4 to 2.4]; p=0.5). There was no difference between groups for the simvastatin safety outcomes. INTERPRETATION Immediately after TIA or minor stroke, patients are at high risk of stroke, which might be reduced by using clopidogrel in addition to aspirin. The haemorrhagic risks of the combination of aspirin and clopidogrel do not seem to offset this potential benefit. We were unable to provide evidence of benefit of simvastatin in this setting. This aggressive prevention approach merits further study.
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Affiliation(s)
- James Kennedy
- Acute Stroke Programme, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Abstract
Background and Purpose—
High-dose human albumin (ALB) is robustly neuroprotective in rodent stroke models. A phase I dose-escalation study was conducted to assess the safety of ALB therapy in ischemic stroke. We analyzed the data for preliminary evidence of treatment efficacy.
Methods—
Eighty-two subjects with acute ischemic stroke (NIH Stroke Scale [NIHSS] of 6 or above) received 25% ALB beginning within 16 hours of stroke onset. Six successive ALB dose tiers were assessed (range, 0.34 to 2.05 g/kg). Forty-two patients also received standard-of-care intravenous tissue plasminogen activator (tPA). Efficacy outcomes were determined at 3 months. We compared the highest three, putatively therapeutic ALB dose tiers (1.37 to 2.05 g/kg) with the lowest three, presumed subtherapeutic doses (0.34 to 1.03 g/kg) and with historical cohort data derived from the NINDS rt-PA Stroke Study.
Results—
After adjusting for the tPA effect, the probability of good outcome (defined as modified Rankin Scale 0 to 1 or NIH Stroke Scale 0 to 1 at 3 months) at the highest three ALB doses was 81% greater than in the lower dose-tiers (relative risk [RR], 1.81; 95% confidence interval [CI], 1.11 to 2.94) and was 95% greater than in the comparable NINDS rt-PA Stroke Study cohort (RR, 1.95; 95% CI, 1.47 to 2.57). The tPA-treated subjects who received higher-dose ALB were three times more likely to achieve a good outcome than subjects receiving lower-dose ALB, suggesting a positive synergistic effect between ALB and tPA.
Conclusions—
Our data suggest that high-dose ALB therapy may be neuroprotective after ischemic stroke. These results have led to a multicenter, randomized, placebo-controlled efficacy trial of ALB in acute ischemic stroke—the ALIAS Phase III Trial.
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Affiliation(s)
- Yuko Y Palesch
- Department of Neurology (D4-5), University of Miami Miller School of Medicine, PO Box 016960, Miami, Florida 33101, USA
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Abstract
Background and Purpose—
In preclinical stroke models, high-dose human albumin confers robust neuroprotection. We investigated the safety and tolerability of this therapy in patients with acute ischemic stroke.
Methods—
The ALIAS (
Al
bumin
i
n
A
cute
S
troke) Pilot Clinical Trial used a multiple-tier, open-label, dose-escalation design. Subjects with acute ischemic stroke (NIH Stroke Scale [NIHSS] of 6 or above) received a 2-hour infusion of 25% human albumin (ALB) beginning within 16 hours of stroke onset. Six successive ALB dose tiers were assessed ranging from 0.34 to 2.05 g/kg. Neurologic and cardiac function was sequentially monitored. At 3 months, the NIHSS, modified Rankin Scale, and Barthel Index were measured.
Results—
Eighty-two subjects (mean age, 65 years) received ALB at 7.8±3.4 hours after stroke onset (mean±standard deviation). Forty-two patients also received standard-of-care intravenous tissue plasminogen activator (tPA). Vital signs were unaltered by ALB treatment. Dose-related increases in plasma albumin and mild hemodilution were maximal at 4 to 12 hours. Age-related plasma brain natriuretic peptide levels increased at 24 hours after ALB but did not predict cardiac adverse events. The sole ALB-related adverse event was mild or moderate pulmonary edema in 13.4% of subjects, which was readily managed with diuretics. In the tPA-treated subgroup, symptomatic intracranial hemorrhage occurred in only one of 42 subjects.
Conclusions—
Twenty-five percent human albumin in doses ranging up to 2.05 g/kg was tolerated by patients with acute ischemic stroke without major dose-limiting complications. tPA therapy did not affect the safety profile of ALB. The companion article presents neurologic outcome data and efficacy analysis in these subjects.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology (D4-5), University of Miami Miller School of Medicine, PO Box 016960, Miami, Florida 33101, USA.
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