N. Rex, J. Ospel, Rosalie V. McDonough, N. Kashani, Leon Rinkel, Brian H. Buck, J. Rempel, Ryan Mctaggart, Raul G Nogueira, Alexandre Y Poppe, Dar Dowlatshahi, Brian A. van Adel, Richard H. Swartz, Ruchir A. Shah, E. Sauvageau, Andrew M. Demchuk, M. Tymianski, Michael D. Hill, M. Goyal
Nerinetide treatment was associated with better clinical outcomes among patients with stroke undergoing endovascular treatment who were not treated with concurrent alteplase in the randomized ESCAPE‐NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke) trial. In patients receiving alteplase, no such effect was seen due to an inactivation of nerinetide by plasmin – the product of tissue plasminogen activation. We hypothesized that improved outcomes in the no‐alteplase patients were associated with reduced infarct growth, a radiological correlate of improved stroke outcomes. Data are from the no‐alteplase stratum of the ESCAPE‐NA1 trial. Patients who underwent computer tomography perfusion (CTP) as part of routine clinical care were included. Admission CTP source data were processed using RAPID software. Infarct core at baseline was defined as areas of relative cerebral blood flow <30% on CTP. Final infarct volume was determined via manual segmentation on 24‐hour CT or magnetic resonance diffusion‐weighted imaging. We compared infarct growth (defined as 24‐hour infarct volume minus CTP‐estimated baseline infarct core) among no‐alteplase patients treated with versus without nerinetide. CTP maps were available in 413/1105 (37%) ESCAPE‐NA1 participants. Of these, 179 (43%) were treated without alteplase, 79 (44%) received nerinetide, and 100 (56%) received placebo. Prior administration of alteplase modified the treatment effect of nerinetide on infarct growth in a multivariable model that was adjusted for age, sex, baseline infarct core volume, expanded Thrombolysis in Cerebral Infarction score, and time from baseline imaging to reperfusion ( P = 0.005). In no‐alteplase patients, infarct growth was larger over 24 hours in the control (34.9 mL interquartile range[IQR] [6.8–127]) versus nerinetide (19.6 mL IQR [1.7–49.1]; P = 0.008) groups. In patients who received prior alteplase (n = 234), there was no difference in infarct growth between those who received placebo versus nerinetide (10.5 mL IQR [−1.3 to 67.4] versus 12.8 mL IQR [0.35–55.5]; P = 0.62). Nerinetide was associated with decreased infarct growth in acute ischemic stroke patients undergoing thrombectomy without concurrent alteplase in the ESCAPE‐NA1 trial.
在ESCAPE-NA1（奈奈内酯治疗急性缺血性中风的疗效和安全性）随机试验中，接受血管内治疗但未同时接受阿替普酶治疗的中风患者接受奈奈内酯治疗可获得更好的临床疗效。在接受阿替普酶治疗的患者中，由于组织纤溶酶原激活的产物--plasmin会使奈瑞内酯失活，因此看不到这种效果。我们假设，不使用阿替普酶患者的预后改善与梗死增生的减少有关，而梗死增生是中风预后改善的放射学相关因素。 数据来自ESCAPE-NA1试验的无阿替普酶分层。作为常规临床治疗的一部分，纳入了接受计算机断层扫描灌注（CTP）的患者。入院时的 CTP 源数据使用 RAPID 软件进行处理。基线时的梗死核心定义为 CTP 上相对脑血流<30%的区域。最终梗死体积通过 24 小时 CT 或磁共振弥散加权成像手动分割确定。我们比较了使用和不使用奈瑞肽治疗的无阿替普酶患者的梗死增长情况（定义为 24 小时梗死体积减去 CTP 估算的基线梗死核心）。 413/1105（37%）名ESCAPE-NA1参与者获得了CTP图谱。其中，179 人（43%）接受了无阿替普酶治疗，79 人（44%）接受了奈瑞奈肽治疗，100 人（56%）接受了安慰剂治疗。在根据年龄、性别、基线梗死核心体积、脑梗死溶栓治疗扩展评分以及从基线成像到再灌注的时间进行调整后建立的多变量模型中，先用阿替普酶可改变奈瑞奈肽对梗死生长的治疗效果（P = 0.005）。在未接受阿替普酶治疗的患者中，对照组（34.9 mL 四分位数间距[IQR][6.8-127]）与奈奈奈德组（19.6 mL IQR [1.7-49.1]; P = 0.008）的梗死在24小时内增长幅度更大。在既往接受过阿替普酶治疗的患者中（n = 234），安慰剂组与奈瑞内酯组在梗死生长方面没有差异（10.5 mL IQR [-1.3 to 67.4] 与 12.8 mL IQR [0.35-55.5]; P = 0.62）。 在ESCAPE-NA1试验中，接受血栓切除术但未同时接受阿替普酶治疗的急性缺血性脑卒中患者中，奈瑞奈肽可减少梗死增生。
{"title":"Nerinetide Reduces Early Infarct Growth Among Stroke Patients Undergoing EVT Without Intravenous Alteplase","authors":"N. Rex, J. Ospel, Rosalie V. McDonough, N. Kashani, Leon Rinkel, Brian H. Buck, J. Rempel, Ryan Mctaggart, Raul G Nogueira, Alexandre Y Poppe, Dar Dowlatshahi, Brian A. van Adel, Richard H. Swartz, Ruchir A. Shah, E. Sauvageau, Andrew M. Demchuk, M. Tymianski, Michael D. Hill, M. Goyal","doi":"10.1161/svin.123.001034","DOIUrl":"https://doi.org/10.1161/svin.123.001034","url":null,"abstract":"\u0000 \u0000 Nerinetide treatment was associated with better clinical outcomes among patients with stroke undergoing endovascular treatment who were not treated with concurrent alteplase in the randomized ESCAPE‐NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke) trial. In patients receiving alteplase, no such effect was seen due to an inactivation of nerinetide by plasmin – the product of tissue plasminogen activation. We hypothesized that improved outcomes in the no‐alteplase patients were associated with reduced infarct growth, a radiological correlate of improved stroke outcomes.\u0000 \u0000 \u0000 \u0000 Data are from the no‐alteplase stratum of the ESCAPE‐NA1 trial. Patients who underwent computer tomography perfusion (CTP) as part of routine clinical care were included. Admission CTP source data were processed using RAPID software. Infarct core at baseline was defined as areas of relative cerebral blood flow <30% on CTP. Final infarct volume was determined via manual segmentation on 24‐hour CT or magnetic resonance diffusion‐weighted imaging. We compared infarct growth (defined as 24‐hour infarct volume minus CTP‐estimated baseline infarct core) among no‐alteplase patients treated with versus without nerinetide.\u0000 \u0000 \u0000 \u0000 \u0000 CTP maps were available in 413/1105 (37%) ESCAPE‐NA1 participants. Of these, 179 (43%) were treated without alteplase, 79 (44%) received nerinetide, and 100 (56%) received placebo. Prior administration of alteplase modified the treatment effect of nerinetide on infarct growth in a multivariable model that was adjusted for age, sex, baseline infarct core volume, expanded Thrombolysis in Cerebral Infarction score, and time from baseline imaging to reperfusion (\u0000 P\u0000 = 0.005). In no‐alteplase patients, infarct growth was larger over 24 hours in the control (34.9 mL interquartile range[IQR] [6.8–127]) versus nerinetide (19.6 mL IQR [1.7–49.1];\u0000 P\u0000 = 0.008) groups. In patients who received prior alteplase (n = 234), there was no difference in infarct growth between those who received placebo versus nerinetide (10.5 mL IQR [−1.3 to 67.4] versus 12.8 mL IQR [0.35–55.5];\u0000 P\u0000 = 0.62).\u0000 \u0000 \u0000 \u0000 \u0000 Nerinetide was associated with decreased infarct growth in acute ischemic stroke patients undergoing thrombectomy without concurrent alteplase in the ESCAPE‐NA1 trial.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"14 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139866560","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
N. Rex, J. Ospel, Rosalie V. McDonough, N. Kashani, Leon Rinkel, Brian H. Buck, J. Rempel, Ryan Mctaggart, Raul G Nogueira, Alexandre Y Poppe, Dar Dowlatshahi, Brian A. van Adel, Richard H. Swartz, Ruchir A. Shah, E. Sauvageau, Andrew M. Demchuk, M. Tymianski, Michael D. Hill, M. Goyal
Nerinetide treatment was associated with better clinical outcomes among patients with stroke undergoing endovascular treatment who were not treated with concurrent alteplase in the randomized ESCAPE‐NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke) trial. In patients receiving alteplase, no such effect was seen due to an inactivation of nerinetide by plasmin – the product of tissue plasminogen activation. We hypothesized that improved outcomes in the no‐alteplase patients were associated with reduced infarct growth, a radiological correlate of improved stroke outcomes. Data are from the no‐alteplase stratum of the ESCAPE‐NA1 trial. Patients who underwent computer tomography perfusion (CTP) as part of routine clinical care were included. Admission CTP source data were processed using RAPID software. Infarct core at baseline was defined as areas of relative cerebral blood flow <30% on CTP. Final infarct volume was determined via manual segmentation on 24‐hour CT or magnetic resonance diffusion‐weighted imaging. We compared infarct growth (defined as 24‐hour infarct volume minus CTP‐estimated baseline infarct core) among no‐alteplase patients treated with versus without nerinetide. CTP maps were available in 413/1105 (37%) ESCAPE‐NA1 participants. Of these, 179 (43%) were treated without alteplase, 79 (44%) received nerinetide, and 100 (56%) received placebo. Prior administration of alteplase modified the treatment effect of nerinetide on infarct growth in a multivariable model that was adjusted for age, sex, baseline infarct core volume, expanded Thrombolysis in Cerebral Infarction score, and time from baseline imaging to reperfusion ( P = 0.005). In no‐alteplase patients, infarct growth was larger over 24 hours in the control (34.9 mL interquartile range[IQR] [6.8–127]) versus nerinetide (19.6 mL IQR [1.7–49.1]; P = 0.008) groups. In patients who received prior alteplase (n = 234), there was no difference in infarct growth between those who received placebo versus nerinetide (10.5 mL IQR [−1.3 to 67.4] versus 12.8 mL IQR [0.35–55.5]; P = 0.62). Nerinetide was associated with decreased infarct growth in acute ischemic stroke patients undergoing thrombectomy without concurrent alteplase in the ESCAPE‐NA1 trial.
在ESCAPE-NA1（奈奈内酯治疗急性缺血性中风的疗效和安全性）随机试验中，接受血管内治疗但未同时接受阿替普酶治疗的中风患者接受奈奈内酯治疗可获得更好的临床疗效。在接受阿替普酶治疗的患者中，由于组织纤溶酶原激活的产物--plasmin会使奈瑞内酯失活，因此看不到这种效果。我们假设，不使用阿替普酶患者的预后改善与梗死增生的减少有关，而梗死增生是中风预后改善的放射学相关因素。 数据来自ESCAPE-NA1试验的无阿替普酶分层。作为常规临床治疗的一部分，纳入了接受计算机断层扫描灌注（CTP）的患者。入院时的 CTP 源数据使用 RAPID 软件进行处理。基线时的梗死核心定义为 CTP 上相对脑血流<30%的区域。最终梗死体积通过 24 小时 CT 或磁共振弥散加权成像手动分割确定。我们比较了使用和不使用奈瑞肽治疗的无阿替普酶患者的梗死增长情况（定义为 24 小时梗死体积减去 CTP 估算的基线梗死核心）。 413/1105（37%）名ESCAPE-NA1参与者获得了CTP图谱。其中，179 人（43%）接受了无阿替普酶治疗，79 人（44%）接受了奈瑞奈肽治疗，100 人（56%）接受了安慰剂治疗。在根据年龄、性别、基线梗死核心体积、脑梗死溶栓治疗扩展评分以及从基线成像到再灌注的时间进行调整后建立的多变量模型中，先用阿替普酶可改变奈瑞奈肽对梗死生长的治疗效果（P = 0.005）。在未接受阿替普酶治疗的患者中，对照组（34.9 mL 四分位数间距[IQR][6.8-127]）与奈奈奈德组（19.6 mL IQR [1.7-49.1]; P = 0.008）的梗死在24小时内增长幅度更大。在既往接受过阿替普酶治疗的患者中（n = 234），安慰剂组与奈瑞内酯组在梗死生长方面没有差异（10.5 mL IQR [-1.3 to 67.4] 与 12.8 mL IQR [0.35-55.5]; P = 0.62）。 在ESCAPE-NA1试验中，接受血栓切除术但未同时接受阿替普酶治疗的急性缺血性脑卒中患者中，奈瑞奈肽可减少梗死增生。
{"title":"Nerinetide Reduces Early Infarct Growth Among Stroke Patients Undergoing EVT Without Intravenous Alteplase","authors":"N. Rex, J. Ospel, Rosalie V. McDonough, N. Kashani, Leon Rinkel, Brian H. Buck, J. Rempel, Ryan Mctaggart, Raul G Nogueira, Alexandre Y Poppe, Dar Dowlatshahi, Brian A. van Adel, Richard H. Swartz, Ruchir A. Shah, E. Sauvageau, Andrew M. Demchuk, M. Tymianski, Michael D. Hill, M. Goyal","doi":"10.1161/svin.123.001034","DOIUrl":"https://doi.org/10.1161/svin.123.001034","url":null,"abstract":"\u0000 \u0000 Nerinetide treatment was associated with better clinical outcomes among patients with stroke undergoing endovascular treatment who were not treated with concurrent alteplase in the randomized ESCAPE‐NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke) trial. In patients receiving alteplase, no such effect was seen due to an inactivation of nerinetide by plasmin – the product of tissue plasminogen activation. We hypothesized that improved outcomes in the no‐alteplase patients were associated with reduced infarct growth, a radiological correlate of improved stroke outcomes.\u0000 \u0000 \u0000 \u0000 Data are from the no‐alteplase stratum of the ESCAPE‐NA1 trial. Patients who underwent computer tomography perfusion (CTP) as part of routine clinical care were included. Admission CTP source data were processed using RAPID software. Infarct core at baseline was defined as areas of relative cerebral blood flow <30% on CTP. Final infarct volume was determined via manual segmentation on 24‐hour CT or magnetic resonance diffusion‐weighted imaging. We compared infarct growth (defined as 24‐hour infarct volume minus CTP‐estimated baseline infarct core) among no‐alteplase patients treated with versus without nerinetide.\u0000 \u0000 \u0000 \u0000 \u0000 CTP maps were available in 413/1105 (37%) ESCAPE‐NA1 participants. Of these, 179 (43%) were treated without alteplase, 79 (44%) received nerinetide, and 100 (56%) received placebo. Prior administration of alteplase modified the treatment effect of nerinetide on infarct growth in a multivariable model that was adjusted for age, sex, baseline infarct core volume, expanded Thrombolysis in Cerebral Infarction score, and time from baseline imaging to reperfusion (\u0000 P\u0000 = 0.005). In no‐alteplase patients, infarct growth was larger over 24 hours in the control (34.9 mL interquartile range[IQR] [6.8–127]) versus nerinetide (19.6 mL IQR [1.7–49.1];\u0000 P\u0000 = 0.008) groups. In patients who received prior alteplase (n = 234), there was no difference in infarct growth between those who received placebo versus nerinetide (10.5 mL IQR [−1.3 to 67.4] versus 12.8 mL IQR [0.35–55.5];\u0000 P\u0000 = 0.62).\u0000 \u0000 \u0000 \u0000 \u0000 Nerinetide was associated with decreased infarct growth in acute ischemic stroke patients undergoing thrombectomy without concurrent alteplase in the ESCAPE‐NA1 trial.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"15 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139806719","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ethan S. Brandler, Elizabeth A. Lancet, Sheree Murphy, Pamela H. Lai, Vincent Carrano, D. Prezant, M. Redlener, D. Ben‐Eli
Due to the increased morbidity and mortality associated with acute cerebral ischemia caused by large vessel occlusions, the New York City (NYC) 9‐1‐1 Emergency Medical Services system implemented the NYC Stroke Triage Protocol with the intention of improving access to endovascular therapy for patients with suspected severe stroke. Successful collaboration between multiple stakeholders enabled the NYC region to develop and implement a new stroke system of care for patients treated by Emergency Medical Services. Descriptive statistics including medians (interquartile range) and proportions were used as appropriate. Continuous data were compared using Mann–Whitney tests for medians and categorical data were compared by using Pearson chi‐square test. Between April 1, 2019 and March 31, 2022, 1337 (83.5%) patients directly transported under the NYC Stroke Triage Protocol by the NYC 9‐1‐1 Emergency Medical Services system to a Thrombectomy Stroke Center had a stroke diagnosis. Patients transported to a more distant Thrombectomy Stroke Center traveled an average of 5.7 minutes longer compared with those who were delivered to the closest Primary Stroke Center but the overall time between first patient contact and first pass at a Thrombectomy Stroke Center was an estimated 98.2 minutes shorter. Approximately 24% of directly transported patients with a stroke diagnosis underwent a thrombectomy. The NYC Stroke Triage Protocol increased access to advanced interventional stroke care for eligible patients by decreasing time to treatment through prehospital identification of patients with severe stroke and directly transporting them to a stroke center capable of providing endovascular therapy.
{"title":"Implementation of a Thrombectomy Stroke Center Triage Program in New York City Emergency Medical Services","authors":"Ethan S. Brandler, Elizabeth A. Lancet, Sheree Murphy, Pamela H. Lai, Vincent Carrano, D. Prezant, M. Redlener, D. Ben‐Eli","doi":"10.1161/svin.123.001117","DOIUrl":"https://doi.org/10.1161/svin.123.001117","url":null,"abstract":"\u0000 \u0000 Due to the increased morbidity and mortality associated with acute cerebral ischemia caused by large vessel occlusions, the New York City (NYC) 9‐1‐1 Emergency Medical Services system implemented the NYC Stroke Triage Protocol with the intention of improving access to endovascular therapy for patients with suspected severe stroke.\u0000 \u0000 \u0000 \u0000 Successful collaboration between multiple stakeholders enabled the NYC region to develop and implement a new stroke system of care for patients treated by Emergency Medical Services. Descriptive statistics including medians (interquartile range) and proportions were used as appropriate. Continuous data were compared using Mann–Whitney tests for medians and categorical data were compared by using Pearson chi‐square test.\u0000 \u0000 \u0000 \u0000 Between April 1, 2019 and March 31, 2022, 1337 (83.5%) patients directly transported under the NYC Stroke Triage Protocol by the NYC 9‐1‐1 Emergency Medical Services system to a Thrombectomy Stroke Center had a stroke diagnosis. Patients transported to a more distant Thrombectomy Stroke Center traveled an average of 5.7 minutes longer compared with those who were delivered to the closest Primary Stroke Center but the overall time between first patient contact and first pass at a Thrombectomy Stroke Center was an estimated 98.2 minutes shorter. Approximately 24% of directly transported patients with a stroke diagnosis underwent a thrombectomy.\u0000 \u0000 \u0000 \u0000 The NYC Stroke Triage Protocol increased access to advanced interventional stroke care for eligible patients by decreasing time to treatment through prehospital identification of patients with severe stroke and directly transporting them to a stroke center capable of providing endovascular therapy.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"277 ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139832420","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Neeharika Krothapalli, Thomas Ortel, Devin McBride, A. de Havenon, L. Sansing, David Hasan, Brian C. Mac Grory
Endovascular thrombectomy (EVT) is one of the most effective therapies for acute ischemic stroke attributable to large‐vessel occlusion but, despite successful treatment, there remains a significant number of patients with disability. The phenomenon of incomplete microcirculatory reperfusion or no reflow is thought to underlie a substantial proportion of cases with unfavorable outcome. This phenomenon likely arises from platelet aggregation and endothelial edema impacting the cerebral microvasculature, vessels that are below the resolution of digital subtraction angiography. Although incomplete microcirculatory reperfusion prevents tissue recovery and poses a significant clinical challenge, there are multiple therapeutic options administered early after recanalization that have been shown to be promising. In this review, we discuss incomplete microcirculatory reperfusion after EVT and highlight various treatment approaches with a particular focus on antiplatelet therapy, including inhibition of the glycoprotein IIb/IIIa receptor pathway. We also review the rigor of previous studies exploring the use of intravenous and intraarterial administration of tirofiban in neurologic disease before EVT, during EVT, after EVT, or as rescue therapy to determine its effect on clinical outcomes.
{"title":"Management of Incomplete Microcirculatory Reperfusion After Endovascular Thrombectomy: Focus on Inhibition of the Glycoprotein IIb/IIIa Receptor Pathway","authors":"Neeharika Krothapalli, Thomas Ortel, Devin McBride, A. de Havenon, L. Sansing, David Hasan, Brian C. Mac Grory","doi":"10.1161/svin.123.001048","DOIUrl":"https://doi.org/10.1161/svin.123.001048","url":null,"abstract":"Endovascular thrombectomy (EVT) is one of the most effective therapies for acute ischemic stroke attributable to large‐vessel occlusion but, despite successful treatment, there remains a significant number of patients with disability. The phenomenon of incomplete microcirculatory reperfusion or no reflow is thought to underlie a substantial proportion of cases with unfavorable outcome. This phenomenon likely arises from platelet aggregation and endothelial edema impacting the cerebral microvasculature, vessels that are below the resolution of digital subtraction angiography. Although incomplete microcirculatory reperfusion prevents tissue recovery and poses a significant clinical challenge, there are multiple therapeutic options administered early after recanalization that have been shown to be promising. In this review, we discuss incomplete microcirculatory reperfusion after EVT and highlight various treatment approaches with a particular focus on antiplatelet therapy, including inhibition of the glycoprotein IIb/IIIa receptor pathway. We also review the rigor of previous studies exploring the use of intravenous and intraarterial administration of tirofiban in neurologic disease before EVT, during EVT, after EVT, or as rescue therapy to determine its effect on clinical outcomes.","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"23 11","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139817947","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Neeharika Krothapalli, Thomas Ortel, Devin McBride, A. de Havenon, L. Sansing, David Hasan, Brian C. Mac Grory
Endovascular thrombectomy (EVT) is one of the most effective therapies for acute ischemic stroke attributable to large‐vessel occlusion but, despite successful treatment, there remains a significant number of patients with disability. The phenomenon of incomplete microcirculatory reperfusion or no reflow is thought to underlie a substantial proportion of cases with unfavorable outcome. This phenomenon likely arises from platelet aggregation and endothelial edema impacting the cerebral microvasculature, vessels that are below the resolution of digital subtraction angiography. Although incomplete microcirculatory reperfusion prevents tissue recovery and poses a significant clinical challenge, there are multiple therapeutic options administered early after recanalization that have been shown to be promising. In this review, we discuss incomplete microcirculatory reperfusion after EVT and highlight various treatment approaches with a particular focus on antiplatelet therapy, including inhibition of the glycoprotein IIb/IIIa receptor pathway. We also review the rigor of previous studies exploring the use of intravenous and intraarterial administration of tirofiban in neurologic disease before EVT, during EVT, after EVT, or as rescue therapy to determine its effect on clinical outcomes.
{"title":"Management of Incomplete Microcirculatory Reperfusion After Endovascular Thrombectomy: Focus on Inhibition of the Glycoprotein IIb/IIIa Receptor Pathway","authors":"Neeharika Krothapalli, Thomas Ortel, Devin McBride, A. de Havenon, L. Sansing, David Hasan, Brian C. Mac Grory","doi":"10.1161/svin.123.001048","DOIUrl":"https://doi.org/10.1161/svin.123.001048","url":null,"abstract":"Endovascular thrombectomy (EVT) is one of the most effective therapies for acute ischemic stroke attributable to large‐vessel occlusion but, despite successful treatment, there remains a significant number of patients with disability. The phenomenon of incomplete microcirculatory reperfusion or no reflow is thought to underlie a substantial proportion of cases with unfavorable outcome. This phenomenon likely arises from platelet aggregation and endothelial edema impacting the cerebral microvasculature, vessels that are below the resolution of digital subtraction angiography. Although incomplete microcirculatory reperfusion prevents tissue recovery and poses a significant clinical challenge, there are multiple therapeutic options administered early after recanalization that have been shown to be promising. In this review, we discuss incomplete microcirculatory reperfusion after EVT and highlight various treatment approaches with a particular focus on antiplatelet therapy, including inhibition of the glycoprotein IIb/IIIa receptor pathway. We also review the rigor of previous studies exploring the use of intravenous and intraarterial administration of tirofiban in neurologic disease before EVT, during EVT, after EVT, or as rescue therapy to determine its effect on clinical outcomes.","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139877878","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ethan S. Brandler, Elizabeth A. Lancet, Sheree Murphy, Pamela H. Lai, Vincent Carrano, D. Prezant, M. Redlener, D. Ben‐Eli
Due to the increased morbidity and mortality associated with acute cerebral ischemia caused by large vessel occlusions, the New York City (NYC) 9‐1‐1 Emergency Medical Services system implemented the NYC Stroke Triage Protocol with the intention of improving access to endovascular therapy for patients with suspected severe stroke. Successful collaboration between multiple stakeholders enabled the NYC region to develop and implement a new stroke system of care for patients treated by Emergency Medical Services. Descriptive statistics including medians (interquartile range) and proportions were used as appropriate. Continuous data were compared using Mann–Whitney tests for medians and categorical data were compared by using Pearson chi‐square test. Between April 1, 2019 and March 31, 2022, 1337 (83.5%) patients directly transported under the NYC Stroke Triage Protocol by the NYC 9‐1‐1 Emergency Medical Services system to a Thrombectomy Stroke Center had a stroke diagnosis. Patients transported to a more distant Thrombectomy Stroke Center traveled an average of 5.7 minutes longer compared with those who were delivered to the closest Primary Stroke Center but the overall time between first patient contact and first pass at a Thrombectomy Stroke Center was an estimated 98.2 minutes shorter. Approximately 24% of directly transported patients with a stroke diagnosis underwent a thrombectomy. The NYC Stroke Triage Protocol increased access to advanced interventional stroke care for eligible patients by decreasing time to treatment through prehospital identification of patients with severe stroke and directly transporting them to a stroke center capable of providing endovascular therapy.
{"title":"Implementation of a Thrombectomy Stroke Center Triage Program in New York City Emergency Medical Services","authors":"Ethan S. Brandler, Elizabeth A. Lancet, Sheree Murphy, Pamela H. Lai, Vincent Carrano, D. Prezant, M. Redlener, D. Ben‐Eli","doi":"10.1161/svin.123.001117","DOIUrl":"https://doi.org/10.1161/svin.123.001117","url":null,"abstract":"\u0000 \u0000 Due to the increased morbidity and mortality associated with acute cerebral ischemia caused by large vessel occlusions, the New York City (NYC) 9‐1‐1 Emergency Medical Services system implemented the NYC Stroke Triage Protocol with the intention of improving access to endovascular therapy for patients with suspected severe stroke.\u0000 \u0000 \u0000 \u0000 Successful collaboration between multiple stakeholders enabled the NYC region to develop and implement a new stroke system of care for patients treated by Emergency Medical Services. Descriptive statistics including medians (interquartile range) and proportions were used as appropriate. Continuous data were compared using Mann–Whitney tests for medians and categorical data were compared by using Pearson chi‐square test.\u0000 \u0000 \u0000 \u0000 Between April 1, 2019 and March 31, 2022, 1337 (83.5%) patients directly transported under the NYC Stroke Triage Protocol by the NYC 9‐1‐1 Emergency Medical Services system to a Thrombectomy Stroke Center had a stroke diagnosis. Patients transported to a more distant Thrombectomy Stroke Center traveled an average of 5.7 minutes longer compared with those who were delivered to the closest Primary Stroke Center but the overall time between first patient contact and first pass at a Thrombectomy Stroke Center was an estimated 98.2 minutes shorter. Approximately 24% of directly transported patients with a stroke diagnosis underwent a thrombectomy.\u0000 \u0000 \u0000 \u0000 The NYC Stroke Triage Protocol increased access to advanced interventional stroke care for eligible patients by decreasing time to treatment through prehospital identification of patients with severe stroke and directly transporting them to a stroke center capable of providing endovascular therapy.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"113 3-6","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139892376","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
L. D’Anna, Andrew Falzon, Oi Yean Wong, Jonsdottir Erla, Nikola Christos, Oliver Spooner, Soma Banerjee, Liqun Zhang, Rob Simister
To date it is uncertain whether the drip‐and‐ship (DS) model (transport to the nearest primary stroke centers) or the mothership (MS) model (direct transportation to the comprehensive stroke center) is the best prehospital stroke system of care to deliver endovascular thrombectomy in patients with basilar artery occlusion. In the present analysis, we aim to investigate the impact of MS versus DS model in patients with basilar artery occlusion treated with endovascular thrombectomy in the London metropolitan area. This is a multicenter observational, investigator‐initiated, retrospective study comparing outcomes (functional independence, defined as modified Rankin scale scores of 0 through 2, the rate of successful reperfusion, and the rate of complications postprocedure) in DS versus MS stroke patients with basilar artery occlusion admitted in 5 thrombectomy capable centers in London (United Kingdom). Of 113 patients, 38 (33.6%) patients were MS and 75 (66.4%) were DS. Between the 2 groups we did not observe statistically significant differences for most of the clinical characteristics. There was a significant difference regarding the rate of functional independence at 3 months between the MS and DS groups, respectively 47.4% versus 36% ( P = 0.047). Rates of complications postprocedure and successful recanalization did not differ between the 2 groups. Multivariable regression analysis demonstrated that MS model was an independent predictor of functional independence at 90 days (odds ratio [OR] 1.17; [95% CI, 1.11–1.26]; P = 0.003 and independent negative predictor of postoperative complications (OR, 0.39; [95% CI, 0.16–0.98]; P = 0.045). Our study showed that MS model was a predictor of functional independence at 3 months and reduced risk of postoperative complications post‐endovascular thrombectomy in patients with basilar artery occlusion in a metropolitan area.
{"title":"Comparison of Mothership Versus Drip‐and‐Ship Models for Endovascular Treatment of Basilar Artery Occlusion in the London Metropolitan Area","authors":"L. D’Anna, Andrew Falzon, Oi Yean Wong, Jonsdottir Erla, Nikola Christos, Oliver Spooner, Soma Banerjee, Liqun Zhang, Rob Simister","doi":"10.1161/svin.123.001077","DOIUrl":"https://doi.org/10.1161/svin.123.001077","url":null,"abstract":"\u0000 \u0000 To date it is uncertain whether the drip‐and‐ship (DS) model (transport to the nearest primary stroke centers) or the mothership (MS) model (direct transportation to the comprehensive stroke center) is the best prehospital stroke system of care to deliver endovascular thrombectomy in patients with basilar artery occlusion. In the present analysis, we aim to investigate the impact of MS versus DS model in patients with basilar artery occlusion treated with endovascular thrombectomy in the London metropolitan area.\u0000 \u0000 \u0000 \u0000 This is a multicenter observational, investigator‐initiated, retrospective study comparing outcomes (functional independence, defined as modified Rankin scale scores of 0 through 2, the rate of successful reperfusion, and the rate of complications postprocedure) in DS versus MS stroke patients with basilar artery occlusion admitted in 5 thrombectomy capable centers in London (United Kingdom).\u0000 \u0000 \u0000 \u0000 \u0000 Of 113 patients, 38 (33.6%) patients were MS and 75 (66.4%) were DS. Between the 2 groups we did not observe statistically significant differences for most of the clinical characteristics. There was a significant difference regarding the rate of functional independence at 3 months between the MS and DS groups, respectively 47.4% versus 36% (\u0000 P\u0000 = 0.047). Rates of complications postprocedure and successful recanalization did not differ between the 2 groups. Multivariable regression analysis demonstrated that MS model was an independent predictor of functional independence at 90 days (odds ratio [OR] 1.17; [95% CI, 1.11–1.26];\u0000 P\u0000 = 0.003 and independent negative predictor of postoperative complications (OR, 0.39; [95% CI, 0.16–0.98];\u0000 P\u0000 = 0.045).\u0000 \u0000 \u0000 \u0000 \u0000 Our study showed that MS model was a predictor of functional independence at 3 months and reduced risk of postoperative complications post‐endovascular thrombectomy in patients with basilar artery occlusion in a metropolitan area.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"14 7","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-01-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139592576","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Juan Felipe Daza‐Ovalle, Charles Esenwa, Matthew Carnevale, James Hu, R. Zampolin, Evan Lipsitz
Symptomatic carotid web with retained thrombus represents a potential source of embolic strokes. However, the absence of diagnostic guidelines contributes to heterogeneity in management recommendations. We present a patient with a right middle cerebral artery stroke attributable to carotid web with retained thrombus. Confirmation was obtained through surgical exploration, given the inconclusive imaging but strong index of suspicion. The presence of carotid web with retained thrombus was confirmed through surgical exploration. Cervical endarterectomy was performed and a carotid web with an associated thrombus was successfully resected. We highlight the importance of having a high index of suspicion and prompt treatment to mitigate the risk of recurrent strokes when suspecting carotid web with retained thrombus.
{"title":"Surgical Exploration and Endarterectomy for Symptomatic Carotid Web With Retained Thrombus","authors":"Juan Felipe Daza‐Ovalle, Charles Esenwa, Matthew Carnevale, James Hu, R. Zampolin, Evan Lipsitz","doi":"10.1161/svin.123.001170","DOIUrl":"https://doi.org/10.1161/svin.123.001170","url":null,"abstract":"\u0000 \u0000 Symptomatic carotid web with retained thrombus represents a potential source of embolic strokes. However, the absence of diagnostic guidelines contributes to heterogeneity in management recommendations.\u0000 \u0000 \u0000 \u0000 We present a patient with a right middle cerebral artery stroke attributable to carotid web with retained thrombus. Confirmation was obtained through surgical exploration, given the inconclusive imaging but strong index of suspicion.\u0000 \u0000 \u0000 \u0000 The presence of carotid web with retained thrombus was confirmed through surgical exploration. Cervical endarterectomy was performed and a carotid web with an associated thrombus was successfully resected.\u0000 \u0000 \u0000 \u0000 We highlight the importance of having a high index of suspicion and prompt treatment to mitigate the risk of recurrent strokes when suspecting carotid web with retained thrombus.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"80 11-12","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-01-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140491774","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
F. Siddiqui, Jeffrey J. Fletcher, A. Elias, S. Dandapat, Sushant P. Kale, Daniel M. Heiferman, Loren Riedy, M. Farooqui, A. Rodriguez-Calienes, J. Vivanco-Suarez, Aditya Pandey, S. Ortega‐Gutierrez
We aimed to determine the current practice patterns among neurointerventional practitioners frequently involved in treating intracranial atherosclerosis‐related large‐vessel occlusion (ICAS‐LVO) during mechanical thrombectomy. We conducted an international online survey of neurointerventionalist members of the Society of Vascular and Interventional Neurology and Society of Neurointerventional Surgery. The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. A total of 184 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 38.3% reported an incidence of 6% to 10% of ICAS‐LVO during mechanical thrombectomy. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis after multiple mechanical thrombectomy attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS)±angioplasty. However, in patients who achieved recanalization with a severe fixed focal stenosis, most (58%) recommended primary medical management. The preferred medication during acute RS was intravenous antiplatelet therapy (65%), and after acute RS, it was dual oral antiplatelet therapy (65%). Fear of hemorrhagic complications (74%) was the most compelling reason not to perform RS±angioplasty. Of respondents, 24% were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before mechanical thrombectomy treatment. The findings of this survey highlight the variations in practice in the medical and endovascular management of ICAS‐LVO. In addition, it informs the situation of equipoise in the treatment decision in ICAS‐LVO, which can then be incorporated into the design of future randomized clinical trials.
{"title":"Patterns of Care in the Diagnosis and Management of Intracranial Atherosclerosis‐Related Large‐Vessel Occlusion: The Rescue‐LVO Survey","authors":"F. Siddiqui, Jeffrey J. Fletcher, A. Elias, S. Dandapat, Sushant P. Kale, Daniel M. Heiferman, Loren Riedy, M. Farooqui, A. Rodriguez-Calienes, J. Vivanco-Suarez, Aditya Pandey, S. Ortega‐Gutierrez","doi":"10.1161/svin.123.001133","DOIUrl":"https://doi.org/10.1161/svin.123.001133","url":null,"abstract":"\u0000 \u0000 We aimed to determine the current practice patterns among neurointerventional practitioners frequently involved in treating intracranial atherosclerosis‐related large‐vessel occlusion (ICAS‐LVO) during mechanical thrombectomy.\u0000 \u0000 \u0000 \u0000 We conducted an international online survey of neurointerventionalist members of the Society of Vascular and Interventional Neurology and Society of Neurointerventional Surgery. The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO.\u0000 \u0000 \u0000 \u0000 A total of 184 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 38.3% reported an incidence of 6% to 10% of ICAS‐LVO during mechanical thrombectomy. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis after multiple mechanical thrombectomy attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS)±angioplasty. However, in patients who achieved recanalization with a severe fixed focal stenosis, most (58%) recommended primary medical management. The preferred medication during acute RS was intravenous antiplatelet therapy (65%), and after acute RS, it was dual oral antiplatelet therapy (65%). Fear of hemorrhagic complications (74%) was the most compelling reason not to perform RS±angioplasty. Of respondents, 24% were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before mechanical thrombectomy treatment.\u0000 \u0000 \u0000 \u0000 The findings of this survey highlight the variations in practice in the medical and endovascular management of ICAS‐LVO. In addition, it informs the situation of equipoise in the treatment decision in ICAS‐LVO, which can then be incorporated into the design of future randomized clinical trials.\u0000","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"56 24","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-01-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139598914","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sara Hassani, Nada El Husseini, Wuwei Feng, Michael Lloyd, A. Quyyumi
Due to the variety of cardiac monitoring devices available after cryptogenic stroke to screen for atrial fibrillation, there is a need to understand the challenges and perceptions of these devices for patients. This article reviews in detail the cardiac monitoring technologies available to screen for atrial fibrillation after cryptogenic stroke/transient ischemic attack, with a focus on what is known regarding patient preferences and compliance in real‐world settings. As the optimal type of device and duration of time to screen for atrial fibrillation after cryptogenic stroke continues to be studied, a shared decision‐making approach that incorporates patient preferences with regard to the monitoring device chosen should be considered. Clinicians should explain to patients the uncertainty about the clinical impact of invasive monitoring, and future studies should aim to qualitatively delineate the viewpoints and comfort levels of patients with stroke regarding the use of implantable versus noninvasive cardiac monitoring.
{"title":"A Patient‐Centered Approach to Cardiac Monitoring After Cryptogenic Stroke: A Review","authors":"Sara Hassani, Nada El Husseini, Wuwei Feng, Michael Lloyd, A. Quyyumi","doi":"10.1161/svin.123.001126","DOIUrl":"https://doi.org/10.1161/svin.123.001126","url":null,"abstract":"Due to the variety of cardiac monitoring devices available after cryptogenic stroke to screen for atrial fibrillation, there is a need to understand the challenges and perceptions of these devices for patients. This article reviews in detail the cardiac monitoring technologies available to screen for atrial fibrillation after cryptogenic stroke/transient ischemic attack, with a focus on what is known regarding patient preferences and compliance in real‐world settings. As the optimal type of device and duration of time to screen for atrial fibrillation after cryptogenic stroke continues to be studied, a shared decision‐making approach that incorporates patient preferences with regard to the monitoring device chosen should be considered. Clinicians should explain to patients the uncertainty about the clinical impact of invasive monitoring, and future studies should aim to qualitatively delineate the viewpoints and comfort levels of patients with stroke regarding the use of implantable versus noninvasive cardiac monitoring.","PeriodicalId":21977,"journal":{"name":"Stroke: Vascular and Interventional Neurology","volume":"140 23","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-01-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139604534","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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