{"title":"Pitfalls of Randomized Controlled Trials in Stroke: How Can We Do Better?","authors":"S. Yaghi, J. Siegler, Thanh N. Nguyen","doi":"10.1161/svin.123.000807","DOIUrl":"https://doi.org/10.1161/svin.123.000807","url":null,"abstract":"","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43069676","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}
How-Chung Cheng, P. Mosimann, Patrick K. Nicholson, J. Schaafsma, E. J. Hendriks
{"title":"Vessel Wall Magnetic Resonance Imaging of Bilateral Distal Internal Carotid Artery Stenosis in Intracranial Giant Cell Arteritis","authors":"How-Chung Cheng, P. Mosimann, Patrick K. Nicholson, J. Schaafsma, E. J. Hendriks","doi":"10.1161/svin.123.000918","DOIUrl":"https://doi.org/10.1161/svin.123.000918","url":null,"abstract":"","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46086491","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}
Kenji Fukutome, S. Aketa, Takaaki Mitsui, Yukiyo Shiraishi, Hiromichi Hayami, Yasutaka Murakami, Ryuta Matsuoka, Mikio Shiba, Rinsei Tei, Y. Shin, Y. Motoyama
A 78‐year‐old man with a mobile lesion was diagnosed with thrombus using carotid ultrasonography, but the lesion was not completely resolved with dual antiplatelet and anticoagulation therapy. Direct visualization by angioscopy showed a white mobile plaque. The carotid artery was stented with a double‐layered stent, as the plaque persisted despite continuing the medical treatment and was linked to an increased risk of cerebral embolism. The plaque was attached to the arterial wall, and it subsequently disappeared. The patient recovered well and no further emboli were observed. Angioscopy is effective for identifying lesions under direct vision. The characteristics and dynamics of plaques may be viewed via angioscopy, which aids in making treatment‐related decisions, particularly in the case of carotid artery plaques.
{"title":"Efficacy of Angioscopy for the Detection of Mobile Carotid Artery Lesions","authors":"Kenji Fukutome, S. Aketa, Takaaki Mitsui, Yukiyo Shiraishi, Hiromichi Hayami, Yasutaka Murakami, Ryuta Matsuoka, Mikio Shiba, Rinsei Tei, Y. Shin, Y. Motoyama","doi":"10.1161/svin.123.000879","DOIUrl":"https://doi.org/10.1161/svin.123.000879","url":null,"abstract":"\u0000 \u0000 A 78‐year‐old man with a mobile lesion was diagnosed with thrombus using carotid ultrasonography, but the lesion was not completely resolved with dual antiplatelet and anticoagulation therapy. Direct visualization by angioscopy showed a white mobile plaque. The carotid artery was stented with a double‐layered stent, as the plaque persisted despite continuing the medical treatment and was linked to an increased risk of cerebral embolism. The plaque was attached to the arterial wall, and it subsequently disappeared. The patient recovered well and no further emboli were observed.\u0000 \u0000 \u0000 \u0000 Angioscopy is effective for identifying lesions under direct vision. The characteristics and dynamics of plaques may be viewed via angioscopy, which aids in making treatment‐related decisions, particularly in the case of carotid artery plaques.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41493997","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}
A. Hoang, Varun S. Shah, J. Granger, D. Iii, P. Youssef, C. Powers, O. Tanweer, L. McCullough, S. Nimjee
The United States is experiencing a rapidly increasing rate of opioid drug abuse. Intravenous drug use (IVDU)‐related endocarditis can lead to significant neurological complications with high morbidity and mortality. When patient care necessitates anticoagulation, the standards for radiographic screening and the risk for intracranial hemorrhage are not clearly elucidated. We conducted a retrospective cohort study involving patients treated for infective endocarditis at a single institution from 2014 to 2018. Patients were grouped based in history of IVDU and their demographics and clinical predictors for intracranial hemorrhage were analyzed. A total of 351 patients met inclusion criteria for this study, of whom 170 patients (48%) had a history of IVDU‐associated endocarditis. IVDU was associated with an increased prevalence of intracranial hemorrhage (25.9% versus 13.9%; P =0.005), including intraparenchymal hemorrhage (12.4% versus 5.1%; P =0.012), subarachnoid hemorrhage (17.6 versus 4.4%; P =0.001), and cerebral microbleeds (14.1% versus 7.2%; P =0.022). IVDU was also associated with an increased incidence of infectious intracranial aneurysm (10.6% versus 1.8%; P =0.001) and brain abscesses (4.7% versus 1.1%; P =0.025). Multivariate analysis showed that the presence of intracranial septic emboli (odds ratio [OR], 18.47 [8.4–40.250]; P =0.001) and infectious intracranial aneurysm (OR, 12.38 [3.24–47.28]; P =0.001) as significant predictive factors for intracranial hemorrhage after presenting with endocarditis. The opioid epidemic has increased the incidence of infective endocarditis and resultant neurovascular complications. IVDU‐associated endocarditis is associated with increased hemorrhagic stroke and more frequent neurodiagnostic imaging.
美国的阿片类药物滥用率正在迅速上升。静脉药物使用(IVDU)相关的心内膜炎可导致严重的神经系统并发症，具有高发病率和死亡率。当病人的护理需要抗凝时，影像学筛查的标准和颅内出血的风险并没有明确的说明。我们进行了一项回顾性队列研究，涉及2014年至2018年在一家机构接受感染性心内膜炎治疗的患者。根据IVDU病史对患者进行分组，分析其人口统计学特征和颅内出血的临床预测因素。共有351名患者符合本研究的纳入标准，其中170名患者(48%)有IVDU相关的心内膜炎病史。IVDU与颅内出血患病率增加相关(25.9% vs 13.9%;P =0.005)，包括肺实质内出血(12.4% vs 5.1%;P =0.012)，蛛网膜下腔出血(17.6%对4.4%;P =0.001)和脑微出血(14.1% vs 7.2%;P = 0.022)。IVDU也与感染性颅内动脉瘤发生率增加相关(10.6% vs 1.8%;P =0.001)和脑脓肿(4.7% vs 1.1%;P = 0.025)。多因素分析显示颅内脓毒性栓塞的存在(优势比[OR]， 18.47 [8.4-40.250];P =0.001)和感染性颅内动脉瘤(OR, 12.38 [3.24-47.28];P =0.001)是心内膜炎后颅内出血的重要预测因素。阿片类药物的流行增加了感染性心内膜炎和由此产生的神经血管并发症的发生率。IVDU相关的心内膜炎与出血性卒中增加和更频繁的神经诊断成像相关。
{"title":"Intravenous Drug Use‐Associated Endocarditis Leads to Increased Intracranial Hemorrhage and Neurological Comorbidities","authors":"A. Hoang, Varun S. Shah, J. Granger, D. Iii, P. Youssef, C. Powers, O. Tanweer, L. McCullough, S. Nimjee","doi":"10.1161/svin.122.000806","DOIUrl":"https://doi.org/10.1161/svin.122.000806","url":null,"abstract":"\u0000 \u0000 The United States is experiencing a rapidly increasing rate of opioid drug abuse. Intravenous drug use (IVDU)‐related endocarditis can lead to significant neurological complications with high morbidity and mortality. When patient care necessitates anticoagulation, the standards for radiographic screening and the risk for intracranial hemorrhage are not clearly elucidated.\u0000 \u0000 \u0000 \u0000 We conducted a retrospective cohort study involving patients treated for infective endocarditis at a single institution from 2014 to 2018. Patients were grouped based in history of IVDU and their demographics and clinical predictors for intracranial hemorrhage were analyzed.\u0000 \u0000 \u0000 \u0000 \u0000 A total of 351 patients met inclusion criteria for this study, of whom 170 patients (48%) had a history of IVDU‐associated endocarditis. IVDU was associated with an increased prevalence of intracranial hemorrhage (25.9% versus 13.9%;\u0000 P\u0000 =0.005), including intraparenchymal hemorrhage (12.4% versus 5.1%;\u0000 P\u0000 =0.012), subarachnoid hemorrhage (17.6 versus 4.4%;\u0000 P\u0000 =0.001), and cerebral microbleeds (14.1% versus 7.2%;\u0000 P\u0000 =0.022). IVDU was also associated with an increased incidence of infectious intracranial aneurysm (10.6% versus 1.8%;\u0000 P\u0000 =0.001) and brain abscesses (4.7% versus 1.1%;\u0000 P\u0000 =0.025). Multivariate analysis showed that the presence of intracranial septic emboli (odds ratio [OR], 18.47 [8.4–40.250];\u0000 P\u0000 =0.001) and infectious intracranial aneurysm (OR, 12.38 [3.24–47.28];\u0000 P\u0000 =0.001) as significant predictive factors for intracranial hemorrhage after presenting with endocarditis.\u0000 \u0000 \u0000 \u0000 \u0000 The opioid epidemic has increased the incidence of infective endocarditis and resultant neurovascular complications. IVDU‐associated endocarditis is associated with increased hemorrhagic stroke and more frequent neurodiagnostic imaging.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44668477","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}
S. Ortega‐Gutierrez, M. Galecio-Castillo, Cynthia B. Zevallos, A. Rodriguez-Calienes, J. Vivanco-Suarez, J. Weng, E. Samaniego, M. Farooqui, C. Derdeyn
Chronic symptomatic internal carotid artery occlusion is an important cause of ischemic strokes. Medical management alone remains suboptimal for secondary prevention, and randomized controlled trials failed to demonstrate the efficacy and safety of extracranial‐intracranial vascular bypass. Carotid occlusion endovascular surgery (COES) is a promising technique, yet its efficacy and safety remain unclear. This systematic review and meta‐analysis included studies in which patients with chronic symptomatic internal carotid artery occlusion underwent treatment with COES and medical management. Primary outcomes included successful reperfusion rates and periprocedural ischemic and hemorrhagic events rates. Secondary outcomes included rates of ischemic events recurrence, other periprocedural events, and mortality. Studies contained at least one of the treatment groups and outcomes of interest. Twenty‐two studies were selected for systematic review, with 18 of them for meta‐analysis. From 14 studies (N=561) the rate of successful recanalization was achieved in 74% of all patients undergoing COES. Thirteen studies (N=534) showed that the rate of COES was 2% both for periprocedural ischemic and hemorrhagic events. At long‐term follow‐up, the COES cohort included a total of 10 studies (N=311) and had a 12% rate of ischemic events, while the medical management group, which included 5 studies (N=313), showed a rate of 19%, with nonsignificant subgroup differences ( P =0.09, I 2 , 12%). Rates of other periprocedural mortality were 4% and 1%, respectively. This meta‐analysis supports the use of COES as a promising and innovative technique for the secondary prevention of symptomatic internal carotid artery occlusion. Our findings suggest that COES may be superior to medical management alone, although further research is needed to fully evaluate its efficacy and safety.
{"title":"Endovascular Surgery Revascularization of Chronic Cervical Carotid Occlusions: Systematic Review and Meta‐Analysis","authors":"S. Ortega‐Gutierrez, M. Galecio-Castillo, Cynthia B. Zevallos, A. Rodriguez-Calienes, J. Vivanco-Suarez, J. Weng, E. Samaniego, M. Farooqui, C. Derdeyn","doi":"10.1161/svin.123.000882","DOIUrl":"https://doi.org/10.1161/svin.123.000882","url":null,"abstract":"Chronic symptomatic internal carotid artery occlusion is an important cause of ischemic strokes. Medical management alone remains suboptimal for secondary prevention, and randomized controlled trials failed to demonstrate the efficacy and safety of extracranial‐intracranial vascular bypass. Carotid occlusion endovascular surgery (COES) is a promising technique, yet its efficacy and safety remain unclear. This systematic review and meta‐analysis included studies in which patients with chronic symptomatic internal carotid artery occlusion underwent treatment with COES and medical management. Primary outcomes included successful reperfusion rates and periprocedural ischemic and hemorrhagic events rates. Secondary outcomes included rates of ischemic events recurrence, other periprocedural events, and mortality. Studies contained at least one of the treatment groups and outcomes of interest. Twenty‐two studies were selected for systematic review, with 18 of them for meta‐analysis. From 14 studies (N=561) the rate of successful recanalization was achieved in 74% of all patients undergoing COES. Thirteen studies (N=534) showed that the rate of COES was 2% both for periprocedural ischemic and hemorrhagic events. At long‐term follow‐up, the COES cohort included a total of 10 studies (N=311) and had a 12% rate of ischemic events, while the medical management group, which included 5 studies (N=313), showed a rate of 19%, with nonsignificant subgroup differences ( P =0.09, I 2 , 12%). Rates of other periprocedural mortality were 4% and 1%, respectively. This meta‐analysis supports the use of COES as a promising and innovative technique for the secondary prevention of symptomatic internal carotid artery occlusion. Our findings suggest that COES may be superior to medical management alone, although further research is needed to fully evaluate its efficacy and safety.","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47221187","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. Rodriguez-villatoro, D. Rodríguez-Luna, M. Muchada, O. Pancorbo, M. Deck, P. Lozano, S. Boned, Á. García‐Tornel, M. Olivé, J. Juega, J. Pagola, M. Rubiera, D. Hernández, C. Molina, C. Piñana, Isabel Rodríguez, M. de Dios, J. Cuevas, M. Requena, L. Gramegna, M. Ribó, A. Tomasello
Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual‐antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear. We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5‐year period receiving either conventional self‐expanding carotid stents (SX) or balloon‐expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow‐up and symptomatic intracranial hemorrhage. A total of 112 patients admitted from April 2016 to April 2021 were included. Dual‐antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) ( P <0.001). Patients in the BX stent group (3/73 [4.1%]) developed a lower rate of symptomatic intracranial hemorrhage compared with patients in the SX stent group (7/39 [17.9%]) ( P =0.031). No differences in extracranial ICA high‐grade restenosis or reocclusion were found between groups at 24 hours after procedure (BX: 20/73 [27.4%]; SX: 9/39 [23.1%]; P =0.673). In patients with acute ischemic stroke and tandem occlusions, a bridging therapy including BX stents with less‐aggressive antiplatelet therapy and subsequent definitive SX stenting to treat extracranial ICA lesions resulted in a lower rate of symptomatic hemorrhagic transformation and no differences in stent patency.
{"title":"Balloon‐Expandable Stenting as a Bridging Therapy in Patients With Acute Stroke and Tandem Occlusions","authors":"N. Rodriguez-villatoro, D. Rodríguez-Luna, M. Muchada, O. Pancorbo, M. Deck, P. Lozano, S. Boned, Á. García‐Tornel, M. Olivé, J. Juega, J. Pagola, M. Rubiera, D. Hernández, C. Molina, C. Piñana, Isabel Rodríguez, M. de Dios, J. Cuevas, M. Requena, L. Gramegna, M. Ribó, A. Tomasello","doi":"10.1161/svin.122.000825","DOIUrl":"https://doi.org/10.1161/svin.122.000825","url":null,"abstract":"\u0000 \u0000 Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual‐antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear.\u0000 \u0000 \u0000 \u0000 We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5‐year period receiving either conventional self‐expanding carotid stents (SX) or balloon‐expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow‐up and symptomatic intracranial hemorrhage.\u0000 \u0000 \u0000 \u0000 \u0000 A total of 112 patients admitted from April 2016 to April 2021 were included. Dual‐antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) (\u0000 P\u0000 <0.001). Patients in the BX stent group (3/73 [4.1%]) developed a lower rate of symptomatic intracranial hemorrhage compared with patients in the SX stent group (7/39 [17.9%]) (\u0000 P\u0000 =0.031). No differences in extracranial ICA high‐grade restenosis or reocclusion were found between groups at 24 hours after procedure (BX: 20/73 [27.4%]; SX: 9/39 [23.1%];\u0000 P\u0000 =0.673).\u0000 \u0000 \u0000 \u0000 \u0000 In patients with acute ischemic stroke and tandem occlusions, a bridging therapy including BX stents with less‐aggressive antiplatelet therapy and subsequent definitive SX stenting to treat extracranial ICA lesions resulted in a lower rate of symptomatic hemorrhagic transformation and no differences in stent patency.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42355004","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}
A. Martinez‐Piñeiro, G. Lucente, M. Hernández-Pérez, Jordi Cortés, A. Arbex, N. Pérez de la Ossa, A. Ramos‐Fransi, M. Almendrote, M. Millán, M. Gomis, L. Dorado, C. Castaño, S. Remollo, P. Cuadras, A. Garrido, Nicolau Guanyabens, Joaquim Broto, E. López‐Cancio, J. Coll‐Cantí, A. Dávalos
Somatosensory evoked potentials may add substantial prognostic value in patients with acute ischemic stroke and contribute to the selection of patients who may benefit from revascularization therapies beyond the accepted therapeutic time windows. We aimed to study the prognostic accuracy of the N20 somatosensory evoked potential component of the ischemic hemisphere in patients with anterior large‐vessel occlusion undergoing endovascular thrombectomy (EVT). Presence and amplitude of the N20 response were recorded before and after EVT. Its adjusted predictive value for functional independence (modified Rankin scale score, ≤2) at day 7 was analyzed by binary logistic regression adjusting by age, mean arterial blood pressure, National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, and serum glucose. N20 predictive power was compared with that of clinical and imaging models by using receiver operating characteristics curve analysis. A total of 223 consecutive patients were studied (mean age, 70 years; median National Institute of Health Stroke Scale score, 18). Somatosensory evoked potential recordings identified the presence of N20 in 110 (49.3%), absence in 58 (26%), and not assessable in 55 patients due to radiofrequency interferences in the angiography room. Before EVT, N20 predicted functional independence with a sensitivity of 93% (95% CI, 78%–98%) and negative predictive value of 93% (95% CI, 80%–98%). The adjusted odds ratio for functional independence was 9.9 (95% CI, 3.1–44.6). In receiver operating characteristics curve analysis, N20 amplitude showed a higher area under the curve than prehospital or in‐hospital variables, including advanced imaging. Sensitivity increased to 100% (95% CI, 0.85–1) when N20 was present after EVT. Somatosensory evoked potential monitoring is a noninvasive and bedside technique that could help eligibility of patients with acute ischemic stroke for EVT and predict functional recovery.
{"title":"Prognostic Accuracy of N20 Somatosensory Potential in Patients With Acute Ischemic Stroke and Endovascular Thrombectomy","authors":"A. Martinez‐Piñeiro, G. Lucente, M. Hernández-Pérez, Jordi Cortés, A. Arbex, N. Pérez de la Ossa, A. Ramos‐Fransi, M. Almendrote, M. Millán, M. Gomis, L. Dorado, C. Castaño, S. Remollo, P. Cuadras, A. Garrido, Nicolau Guanyabens, Joaquim Broto, E. López‐Cancio, J. Coll‐Cantí, A. Dávalos","doi":"10.1161/svin.122.000735","DOIUrl":"https://doi.org/10.1161/svin.122.000735","url":null,"abstract":"\u0000 \u0000 Somatosensory evoked potentials may add substantial prognostic value in patients with acute ischemic stroke and contribute to the selection of patients who may benefit from revascularization therapies beyond the accepted therapeutic time windows. We aimed to study the prognostic accuracy of the N20 somatosensory evoked potential component of the ischemic hemisphere in patients with anterior large‐vessel occlusion undergoing endovascular thrombectomy (EVT).\u0000 \u0000 \u0000 \u0000 Presence and amplitude of the N20 response were recorded before and after EVT. Its adjusted predictive value for functional independence (modified Rankin scale score, ≤2) at day 7 was analyzed by binary logistic regression adjusting by age, mean arterial blood pressure, National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, and serum glucose. N20 predictive power was compared with that of clinical and imaging models by using receiver operating characteristics curve analysis.\u0000 \u0000 \u0000 \u0000 A total of 223 consecutive patients were studied (mean age, 70 years; median National Institute of Health Stroke Scale score, 18). Somatosensory evoked potential recordings identified the presence of N20 in 110 (49.3%), absence in 58 (26%), and not assessable in 55 patients due to radiofrequency interferences in the angiography room. Before EVT, N20 predicted functional independence with a sensitivity of 93% (95% CI, 78%–98%) and negative predictive value of 93% (95% CI, 80%–98%). The adjusted odds ratio for functional independence was 9.9 (95% CI, 3.1–44.6). In receiver operating characteristics curve analysis, N20 amplitude showed a higher area under the curve than prehospital or in‐hospital variables, including advanced imaging. Sensitivity increased to 100% (95% CI, 0.85–1) when N20 was present after EVT.\u0000 \u0000 \u0000 \u0000 Somatosensory evoked potential monitoring is a noninvasive and bedside technique that could help eligibility of patients with acute ischemic stroke for EVT and predict functional recovery.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41862925","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, J. Fletcher, Andrew V. Barnes, Alayna N. Henry, A. Elias, G. Rajah, Alexis Carroll PA‐C, S. Dandapat, K. Ume, M. Farooqui, A. Rodriguez-Calienes, A. Pandey, S. Ortega‐Gutierrez
Intracranial atherosclerosis related large vessel occlusion (ICAS‐LVO) is the major cause of failed mechanical thrombectomy. ICAS‐LVO causes reocclusion or a fixed focal stenosis, leading to suboptimal revascularization and poor functional outcomes. We aimed to externally validate 4 preidentified imaging biomarkers of ICAS‐LVO: absent hyperdense sign, Hounsfield units (Hu ratio ≤1.1 and Delta Hu <6) and truncal‐type occlusion, observed on admission noncontrast computed tomography and computed tomography angiography in patients presenting with emergent large‐vessel occlusion (ELVO). We conducted a retrospective cohort observational study of consecutive patients presenting with acute M1/terminal internal carotid artery occlusions undergoing mechanical thrombectomy. Inability to locate a hyperdense vessel on noncontrast computed tomography at the corresponding ELVO on computed tomography angiography was labeled absent hyperdense sign. Delta Hu and Hu ratio were defined as the difference and ratio of the Hu of the ELVO on noncontrast computed tomography and its mirror contralateral patent vessel, respectively. ELVO was classified as truncal‐type occlusion if the bifurcation distal to the occlusion was spared on computed tomography angiography. ICAS‐LVO was defined as the presence of fixed focal stenosis or reocclusion after mechanical thrombectomy. Statistical analysis was performed using C statistics, receiver operating characteristic curve analysis, and multivariate logistic regression. Of 161 patients, 30 (18.6%) had suspected ICAS‐LVO. Absent hyperdense sign had a sensitivity of 90% and specificity of 87% (area under the curve [AUC], 0.88), in predicting ICAS‐LVO. Hu ratio ≤1.1 (AUC, 0.89) and Delta Hu <6 (AUC, 0.96) had sensitivity of 100% and 97% and specificity of 79% and 95%, respectively. Truncal‐type occlusion showed a sensitivity of 75% and specificity of 98% (AUC, 0.87). When comparing receiver operating characteristic AUC, Delta Hu <6 was significantly better than absent hyperdense sign ( P =0.006); Hu ratio ≤1.1 ( P =0.006); and truncal‐type occlusion ( P =0.02). Combination of neuroimaging biomarkers using noncontrast computed tomography and computed tomography angiography in ELVO identify ICAS‐LVO with high predictive power. Larger, prospective, multicenter studies are warranted to further evaluate their effectiveness in diagnosing ICAS‐LVO.
{"title":"External Validation of Atherosclerotic Neuroimaging Biomarkers in Emergent Large‐Vessel Occlusion","authors":"F. Siddiqui, J. Fletcher, Andrew V. Barnes, Alayna N. Henry, A. Elias, G. Rajah, Alexis Carroll PA‐C, S. Dandapat, K. Ume, M. Farooqui, A. Rodriguez-Calienes, A. Pandey, S. Ortega‐Gutierrez","doi":"10.1161/svin.123.000850","DOIUrl":"https://doi.org/10.1161/svin.123.000850","url":null,"abstract":"\u0000 \u0000 Intracranial atherosclerosis related large vessel occlusion (ICAS‐LVO) is the major cause of failed mechanical thrombectomy. ICAS‐LVO causes reocclusion or a fixed focal stenosis, leading to suboptimal revascularization and poor functional outcomes. We aimed to externally validate 4 preidentified imaging biomarkers of ICAS‐LVO: absent hyperdense sign, Hounsfield units (Hu ratio ≤1.1 and Delta Hu <6) and truncal‐type occlusion, observed on admission noncontrast computed tomography and computed tomography angiography in patients presenting with emergent large‐vessel occlusion (ELVO).\u0000 \u0000 \u0000 \u0000 We conducted a retrospective cohort observational study of consecutive patients presenting with acute M1/terminal internal carotid artery occlusions undergoing mechanical thrombectomy. Inability to locate a hyperdense vessel on noncontrast computed tomography at the corresponding ELVO on computed tomography angiography was labeled absent hyperdense sign. Delta Hu and Hu ratio were defined as the difference and ratio of the Hu of the ELVO on noncontrast computed tomography and its mirror contralateral patent vessel, respectively. ELVO was classified as truncal‐type occlusion if the bifurcation distal to the occlusion was spared on computed tomography angiography. ICAS‐LVO was defined as the presence of fixed focal stenosis or reocclusion after mechanical thrombectomy. Statistical analysis was performed using C statistics, receiver operating characteristic curve analysis, and multivariate logistic regression.\u0000 \u0000 \u0000 \u0000 \u0000 Of 161 patients, 30 (18.6%) had suspected ICAS‐LVO. Absent hyperdense sign had a sensitivity of 90% and specificity of 87% (area under the curve [AUC], 0.88), in predicting ICAS‐LVO. Hu ratio ≤1.1 (AUC, 0.89) and Delta Hu <6 (AUC, 0.96) had sensitivity of 100% and 97% and specificity of 79% and 95%, respectively. Truncal‐type occlusion showed a sensitivity of 75% and specificity of 98% (AUC, 0.87). When comparing receiver operating characteristic AUC, Delta Hu <6 was significantly better than absent hyperdense sign (\u0000 P\u0000 =0.006); Hu ratio ≤1.1 (\u0000 P\u0000 =0.006); and truncal‐type occlusion (\u0000 P\u0000 =0.02).\u0000 \u0000 \u0000 \u0000 \u0000 Combination of neuroimaging biomarkers using noncontrast computed tomography and computed tomography angiography in ELVO identify ICAS‐LVO with high predictive power. Larger, prospective, multicenter studies are warranted to further evaluate their effectiveness in diagnosing ICAS‐LVO.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41580554","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}
S. Sanchez, Jacob M. Miller, Matthew T Jones, Diego J Ojeda, E. Samaniego
Plaque enhancement after gadolinium contrast administration may assess plaque instability and response to medical therapy. We used high‐resolution vessel wall imaging to evaluate changes in plaque morphologic pattern and enhancement after treatment with high‐intensity statins. Patients with a history of stroke or transient ischemic attack attributable to intracranial atherosclerotic disease underwent 7‐T high‐resolution vessel wall imaging. T1 and T1+gadolinium sequences were obtained at baseline. Follow‐up images were acquired at a minimum of 6 months after the initial scan. Low‐density lipoprotein levels were also recorded at baseline and at follow‐up, after maximal medical therapy was started. Plaque burden, degree of stenosis, and area degree of stenosis were calculated at baseline and follow‐up. Gadolinium enhancement was quantified using a 3‐dimensional pipeline for plaque analysis. Five patients were included. The mean age was 56 years, and the average time to follow‐up imaging was 17.7 months. Low‐density lipoprotein decreased from a mean of 122 to 111 mg/dL at follow‐up. Plaque burden decreased from μ=76% to 60%, area degree of stenosis decreased from μ=61% to 56%, and gadolinium uptake decreased from a mean of μ=4.11 to 3.76. Furthermore, a lower low‐density lipoprotein at follow‐up was correlated with decreased plaque burden ( r =0.86), lower area degree of stenosis ( r =0.8), and less gadolinium uptake ( r =0.82). Plaque morphologic pattern and gadolinium uptake changed at follow‐up with high‐intensity statin therapy. High‐resolution vessel wall imaging shows promise in assessing plaque response to medical therapy.
{"title":"Intracranial Atherosclerotic Plaque Morphologic Pattern and Enhancement Change With High‐Intensity Statin Therapy","authors":"S. Sanchez, Jacob M. Miller, Matthew T Jones, Diego J Ojeda, E. Samaniego","doi":"10.1161/svin.123.000942","DOIUrl":"https://doi.org/10.1161/svin.123.000942","url":null,"abstract":"\u0000 \u0000 Plaque enhancement after gadolinium contrast administration may assess plaque instability and response to medical therapy. We used high‐resolution vessel wall imaging to evaluate changes in plaque morphologic pattern and enhancement after treatment with high‐intensity statins.\u0000 \u0000 \u0000 \u0000 Patients with a history of stroke or transient ischemic attack attributable to intracranial atherosclerotic disease underwent 7‐T high‐resolution vessel wall imaging. T1 and T1+gadolinium sequences were obtained at baseline. Follow‐up images were acquired at a minimum of 6 months after the initial scan. Low‐density lipoprotein levels were also recorded at baseline and at follow‐up, after maximal medical therapy was started. Plaque burden, degree of stenosis, and area degree of stenosis were calculated at baseline and follow‐up. Gadolinium enhancement was quantified using a 3‐dimensional pipeline for plaque analysis.\u0000 \u0000 \u0000 \u0000 \u0000 Five patients were included. The mean age was 56 years, and the average time to follow‐up imaging was 17.7 months. Low‐density lipoprotein decreased from a mean of 122 to 111 mg/dL at follow‐up. Plaque burden decreased from μ=76% to 60%, area degree of stenosis decreased from μ=61% to 56%, and gadolinium uptake decreased from a mean of μ=4.11 to 3.76. Furthermore, a lower low‐density lipoprotein at follow‐up was correlated with decreased plaque burden (\u0000 r\u0000 =0.86), lower area degree of stenosis (\u0000 r\u0000 =0.8), and less gadolinium uptake (\u0000 r\u0000 =0.82).\u0000 \u0000 \u0000 \u0000 \u0000 Plaque morphologic pattern and gadolinium uptake changed at follow‐up with high‐intensity statin therapy. High‐resolution vessel wall imaging shows promise in assessing plaque response to medical therapy.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46417382","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}
Á. García‐Tornel, P. Lozano, M. Rubiera, M. Requena, M. Olivé-Gadea, M. Muchada, J. Juega, F. Rizzo, N. Rodriguez-villatoro, J. Pagola, D. Rodríguez-Luna, S. Boned, L. Dorado, Xavier Jiménez, Angels Soto, P. Cardona, X. Urra, Á. Chamorro, F. Purroy, M. Terceño, Y. Silva, A. Flores, X. Ustrell, J. Zaragoza, J. Roquer, J. Kuprinski, D. Cocho, E. Palomeras, M. Gómez-Choco, D. Cánovas, J. Martí-Fàbregas, Natalia Más, S. Abilleira, C. Molina, M. Ribó, N. P. de la Ossa
Our goal is to evaluate whether the administration of thrombolytic treatment has varying effects on clinical and radiological outcomes in patients with large‐vessel occlusion stroke, based on the type of stroke center where the treatment was given (thrombectomy‐capable center versus local stroke center). We included patients with an acute ischemic large‐vessel occlusion stroke who were directly admitted to thrombectomy‐capable centers and treated with endovascular thrombectomy, or were transferred from local stroke centers as thrombectomy candidates, in Catalonia, Spain, between 2017 and 2021. The primary outcome was the shift analysis on the modified Rankin scale score at 90 days. Secondary outcomes included death at 90 days and the rate of parenchymal hemorrhage and successful reperfusion. Inverse‐probability weighting clustered at the type of stroke center was used to estimate the effects. The analysis included 2268 patients directly admitted to thrombectomy‐capable centers, of whom 975 (49%) were treated with thrombolysis, and 938 patients transferred from local stroke centers, of whom 580 (66%) were treated with thrombolysis and 616 (67%) were treated with thrombectomy. Mean age was 72 (SD ±13) years, median National Institute of Health Stroke Scale score was 17 (interquartile range, 12–21), and 1363 patients were women (48%). Patients treated with intravenous thrombolysis were younger, had shorter time from onset to first image, higher Alberta Stroke Program Early Computed Tomography Score, and lower rates of wake‐up stroke, atrial fibrillation, and anticoagulation intake. Patients treated with thrombolysis had better functional outcome at 90 days, with no difference between patients directly admitted to thrombectomy‐capable centers (adjusted common odds ratio [acOR], 1.50 [95% CI, 1.24–1.81]) and patients transferred from local stroke centers (acOR, 1.44 [95% CI, 1.04–2.01]). Patients treated with intravenous thrombolysis had lower death rate, higher rate of parenchymal hematoma, and similar rate of successful reperfusion, with no difference according to type of center ( P interaction >0.1). Administration of intravenous thrombolysis in patients with a large‐vessel stroke with intention of thrombectomy was associated with lower degrees of disability, lower death rate, and higher rates of parenchymal hematoma both in thrombectomy‐capable centers and in local stroke centers.
{"title":"Thrombolysis in Patients With Large‐Vessel Occlusion Directly Admitted or Transferred to a Thrombectomy Center: A Population‐Based Study","authors":"Á. García‐Tornel, P. Lozano, M. Rubiera, M. Requena, M. Olivé-Gadea, M. Muchada, J. Juega, F. Rizzo, N. Rodriguez-villatoro, J. Pagola, D. Rodríguez-Luna, S. Boned, L. Dorado, Xavier Jiménez, Angels Soto, P. Cardona, X. Urra, Á. Chamorro, F. Purroy, M. Terceño, Y. Silva, A. Flores, X. Ustrell, J. Zaragoza, J. Roquer, J. Kuprinski, D. Cocho, E. Palomeras, M. Gómez-Choco, D. Cánovas, J. Martí-Fàbregas, Natalia Más, S. Abilleira, C. Molina, M. Ribó, N. P. de la Ossa","doi":"10.1161/svin.122.000760","DOIUrl":"https://doi.org/10.1161/svin.122.000760","url":null,"abstract":"\u0000 \u0000 Our goal is to evaluate whether the administration of thrombolytic treatment has varying effects on clinical and radiological outcomes in patients with large‐vessel occlusion stroke, based on the type of stroke center where the treatment was given (thrombectomy‐capable center versus local stroke center).\u0000 \u0000 \u0000 \u0000 We included patients with an acute ischemic large‐vessel occlusion stroke who were directly admitted to thrombectomy‐capable centers and treated with endovascular thrombectomy, or were transferred from local stroke centers as thrombectomy candidates, in Catalonia, Spain, between 2017 and 2021. The primary outcome was the shift analysis on the modified Rankin scale score at 90 days. Secondary outcomes included death at 90 days and the rate of parenchymal hemorrhage and successful reperfusion. Inverse‐probability weighting clustered at the type of stroke center was used to estimate the effects.\u0000 \u0000 \u0000 \u0000 \u0000 The analysis included 2268 patients directly admitted to thrombectomy‐capable centers, of whom 975 (49%) were treated with thrombolysis, and 938 patients transferred from local stroke centers, of whom 580 (66%) were treated with thrombolysis and 616 (67%) were treated with thrombectomy. Mean age was 72 (SD ±13) years, median National Institute of Health Stroke Scale score was 17 (interquartile range, 12–21), and 1363 patients were women (48%). Patients treated with intravenous thrombolysis were younger, had shorter time from onset to first image, higher Alberta Stroke Program Early Computed Tomography Score, and lower rates of wake‐up stroke, atrial fibrillation, and anticoagulation intake. Patients treated with thrombolysis had better functional outcome at 90 days, with no difference between patients directly admitted to thrombectomy‐capable centers (adjusted common odds ratio [acOR], 1.50 [95% CI, 1.24–1.81]) and patients transferred from local stroke centers (acOR, 1.44 [95% CI, 1.04–2.01]). Patients treated with intravenous thrombolysis had lower death rate, higher rate of parenchymal hematoma, and similar rate of successful reperfusion, with no difference according to type of center (\u0000 P\u0000 interaction\u0000 >0.1).\u0000 \u0000 \u0000 \u0000 \u0000 Administration of intravenous thrombolysis in patients with a large‐vessel stroke with intention of thrombectomy was associated with lower degrees of disability, lower death rate, and higher rates of parenchymal hematoma both in thrombectomy‐capable centers and in local stroke centers.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44097793","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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