Fumiaki Kanamori, Syuntaro Takasu, N. Hatano, Yoshio Araki, Y. Seki, R. Saito
Revascularization for both anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories in patients with moyamoya disease is often performed in a single operation. The influence of craniotomy type on postoperative outcomes has not been investigated. This study aimed to clarify the effects of craniotomy type on acute postoperative outcomes after combined revascularization by comparing 2‐piece, and large 1‐piece craniotomy approaches. This retrospective study included 337 consecutive combined revascularizations of the ACA and MCA territories in patients with moyamoya disease. Surgeries were classified into 2‐piece and large 1‐piece craniotomy groups. For indirect bypass, the following methods were used: (1) large 1‐piece craniotomy and encephalo‐myo‐galeo‐periosteal‐synangiosis for the MCA and ACA territories; (2) 2‐piece craniotomy and encephalo‐myo‐synangiosis for the MCA territory and encephalo‐periosteal‐synangiosis for the ACA territory. Acute postoperative outcomes were compared between the groups. Two‐piece and large 1‐piece craniotomies were performed in 230 and 107 patients, respectively. The incidence of radiological and symptomatic infarction tended to be lower in the 2‐piece craniotomy group than that in the large 1‐piece craniotomy group (3.9% versus 11.2%; P =0.014, and 2.6% versus 6.5%; P =0.12, respectively). Logistic regression adjusted for potential confounders further explained the relationship between craniotomy type and radiological infarction (large 1‐piece/2‐piece craniotomy: odds ratio, 3.1; 95% CI, 1.2–7.6; P =0.015). In combined revascularization of the ACA and MCA territories in moyamoya disease, 2‐piece craniotomy may reduce the risk of postoperative cerebral infarction.
烟雾病患者大脑前动脉(ACA)和大脑中动脉(MCA)区域的血运重建术通常在一次手术中完成。开颅类型对术后预后的影响尚未研究。本研究旨在通过比较2片开颅术和大1片开颅术，阐明开颅术式对联合血运重建术后急性预后的影响。本回顾性研究包括337例烟雾病患者ACA和MCA区域连续联合血运重建术。手术分为2片开颅组和大1片开颅组。对于间接旁路手术，采用以下方法:(1)大1片开颅术和脑-肌- galeo -骨膜-合并术治疗MCA和ACA区域;(2) 2片开颅术和脑-肌-合并症用于MCA区域，脑-骨膜-合并症用于ACA区域。比较两组急性术后预后。分别对230例和107例患者进行了2片和1片大开颅手术。2片开颅组放射学和症状性梗死的发生率往往低于大1片开颅组(3.9% vs 11.2%;P =0.014, 2.6% vs 6.5%;P =0.12)。经潜在混杂因素调整后的Logistic回归进一步解释了开颅手术类型与影像学梗死之间的关系(大1片/2片开颅术:优势比为3.1;95% ci, 1.2-7.6;P = 0.015)。在烟雾病的ACA和MCA区域联合血运重建术中，2片开颅术可降低术后脑梗死的风险。
{"title":"Two‐Piece Craniotomy Is Associated With Improved Postoperative Outcomes of Combined Revascularization in Patients With Moyamoya Disease","authors":"Fumiaki Kanamori, Syuntaro Takasu, N. Hatano, Yoshio Araki, Y. Seki, R. Saito","doi":"10.1161/svin.122.000759","DOIUrl":"https://doi.org/10.1161/svin.122.000759","url":null,"abstract":"\u0000 \u0000 Revascularization for both anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories in patients with moyamoya disease is often performed in a single operation. The influence of craniotomy type on postoperative outcomes has not been investigated. This study aimed to clarify the effects of craniotomy type on acute postoperative outcomes after combined revascularization by comparing 2‐piece, and large 1‐piece craniotomy approaches.\u0000 \u0000 \u0000 \u0000 This retrospective study included 337 consecutive combined revascularizations of the ACA and MCA territories in patients with moyamoya disease. Surgeries were classified into 2‐piece and large 1‐piece craniotomy groups. For indirect bypass, the following methods were used: (1) large 1‐piece craniotomy and encephalo‐myo‐galeo‐periosteal‐synangiosis for the MCA and ACA territories; (2) 2‐piece craniotomy and encephalo‐myo‐synangiosis for the MCA territory and encephalo‐periosteal‐synangiosis for the ACA territory. Acute postoperative outcomes were compared between the groups.\u0000 \u0000 \u0000 \u0000 \u0000 Two‐piece and large 1‐piece craniotomies were performed in 230 and 107 patients, respectively. The incidence of radiological and symptomatic infarction tended to be lower in the 2‐piece craniotomy group than that in the large 1‐piece craniotomy group (3.9% versus 11.2%;\u0000 P\u0000 =0.014, and 2.6% versus 6.5%;\u0000 P\u0000 =0.12, respectively). Logistic regression adjusted for potential confounders further explained the relationship between craniotomy type and radiological infarction (large 1‐piece/2‐piece craniotomy: odds ratio, 3.1; 95% CI, 1.2–7.6;\u0000 P\u0000 =0.015).\u0000 \u0000 \u0000 \u0000 \u0000 In combined revascularization of the ACA and MCA territories in moyamoya disease, 2‐piece craniotomy may reduce the risk of postoperative cerebral infarction.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46822693","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}
Pub Date : 2023-05-01Epub Date: 2023-03-02DOI: 10.1161/svin.122.000644
Pedro Norat, Jennifer D Sokolowski, Catherine M Gorick, Sauson Soldozy, Jeyan S Kumar, Youngrok Chae, Kaan Yagmurlu, Joelle Nilak, Khadijeh A Sharifi, Melanie Walker, Michael R Levitt, Alexander L Klibanov, Zhen Yan, Richard J Price, Petr Tvrdik, M Yashar S Kalani
Background-: Transplantation of autologous mitochondria into ischemic tissue may mitigate injury caused by ischemia and reperfusion.
Methods-: Using murine stroke models of middle cerebral artery occlusion, we sought to evaluate feasibility of delivery of viable mitochondria to ischemic brain parenchyma. We evaluated the effects of concurrent focused ultrasound activation of microbubbles, which serves to open the blood-brain barrier, on efficacy of delivery of mitochondria.
Results-: Following intra-arterial delivery, mitochondria distribute through the stroked hemisphere and integrate into neural and glial cells in the brain parenchyma. Consistent with functional integration in the ischemic tissue, the transplanted mitochondria elevate concentration of adenosine triphosphate in the stroked hemisphere, reduce infarct volume and increase cell viability. Additional of focused ultrasound leads to improved blood brain barrier opening without hemorrhagic complications.
Conclusions-: Our results have implications for the development of interventional strategies after ischemic stroke and suggest a novel potential modality of therapy after mechanical thrombectomy.
{"title":"Intraarterial Transplantation of Mitochondria After Ischemic Stroke Reduces Cerebral Infarction.","authors":"Pedro Norat, Jennifer D Sokolowski, Catherine M Gorick, Sauson Soldozy, Jeyan S Kumar, Youngrok Chae, Kaan Yagmurlu, Joelle Nilak, Khadijeh A Sharifi, Melanie Walker, Michael R Levitt, Alexander L Klibanov, Zhen Yan, Richard J Price, Petr Tvrdik, M Yashar S Kalani","doi":"10.1161/svin.122.000644","DOIUrl":"10.1161/svin.122.000644","url":null,"abstract":"<p><strong>Background-: </strong>Transplantation of autologous mitochondria into ischemic tissue may mitigate injury caused by ischemia and reperfusion.</p><p><strong>Methods-: </strong>Using murine stroke models of middle cerebral artery occlusion, we sought to evaluate feasibility of delivery of viable mitochondria to ischemic brain parenchyma. We evaluated the effects of concurrent focused ultrasound activation of microbubbles, which serves to open the blood-brain barrier, on efficacy of delivery of mitochondria.</p><p><strong>Results-: </strong>Following intra-arterial delivery, mitochondria distribute through the stroked hemisphere and integrate into neural and glial cells in the brain parenchyma. Consistent with functional integration in the ischemic tissue, the transplanted mitochondria elevate concentration of adenosine triphosphate in the stroked hemisphere, reduce infarct volume and increase cell viability. Additional of focused ultrasound leads to improved blood brain barrier opening without hemorrhagic complications.</p><p><strong>Conclusions-: </strong>Our results have implications for the development of interventional strategies after ischemic stroke and suggest a novel potential modality of therapy after mechanical thrombectomy.</p>","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":"3 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10399028/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9950485","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Thrombectomy in Patients With Active Malignancy","authors":"J. Siegler, Thanh N. Nguyen","doi":"10.1161/svin.123.000835","DOIUrl":"https://doi.org/10.1161/svin.123.000835","url":null,"abstract":"","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44464838","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. Singh, F. Bala, N. Kashani, M. Horn, J. Stang, A. Demchuk, Michael D. Hill, M. Almekhlafi, J. Holodinsky
The benefit of endovascular thrombectomy for medium‐vessel occlusion (MeVO) strokes is unclear. We used 90‐day home time to explore outcomes in patients with MeVO versus large‐vessel occlusions treated with endovascular thrombectomy. Data are from the QuICR (Quality Improvement and Clinical Research) provincial stroke registry and linked administrative data to identify patients who underwent endovascular thrombectomy in our center from January 2015 to December 2020. Imaging data were scored by 2‐physician consensus. We defined MeVO as occlusion beyond and including M2–middle cerebral artery, A2–anterior cerebral artery, or P2–posterior cerebral artery segments. Successful reperfusion was defined as Thrombolysis in Cerebral ischemia grades (≥2b/3). The primary outcome was patient home time (the number of nights a patient is back at their premorbid living situation without an increase in level of care within 90 days of the stroke) using random forest regression. Covariate contribution to home time was determined using partial dependence plots. Among 663 patients who underwent endovascular thrombectomy, 139 (20.9%) had MeVO (median age, 71 years; 50.4% women; median National Institutes of Health Stroke Scale, 16). The majority (82%) had good pial collaterals, 10.4% had a tandem extracranial carotid occlusion or stenosis, and 41.7% received intravenous thrombolysis. The most common site of occlusion was M2–middle cerebral artery (58.3%). One hundred eighteen (86.7%) patients achieved successful reperfusion (Thrombolysis in Cerebral Ischemia grades ≥2b/3). Using partial dependence plots, the mean predicted home times were similar in patients with MeVO (45.5 days) versus large‐vessel occlusions (44.6 days). Factors predicting lower 90‐day home time in patients with MeVOs were diabetes (−8.7 days), hypertension (−6.5 days), and atrial fibrillation (−3.5 days). There was no meaningful difference in predicted 90‐day home‐time by sex, baseline National Institutes of Health Stroke Scale, collateral grade, or thrombolysis. Patients with MeVO who are selected for endovascular therapy with similar demographic and clinical profiles to large‐vessel occlusions can achieve similar 90‐day home time outcomes to large‐vessel occlusions.
{"title":"Prediction of 90‐Day Home Time Among Patients With Medium‐Vessel Occlusion Undergoing Endovascular Thrombectomy","authors":"N. Singh, F. Bala, N. Kashani, M. Horn, J. Stang, A. Demchuk, Michael D. Hill, M. Almekhlafi, J. Holodinsky","doi":"10.1161/svin.122.000748","DOIUrl":"https://doi.org/10.1161/svin.122.000748","url":null,"abstract":"\u0000 \u0000 The benefit of endovascular thrombectomy for medium‐vessel occlusion (MeVO) strokes is unclear. We used 90‐day home time to explore outcomes in patients with MeVO versus large‐vessel occlusions treated with endovascular thrombectomy.\u0000 \u0000 \u0000 \u0000 Data are from the QuICR (Quality Improvement and Clinical Research) provincial stroke registry and linked administrative data to identify patients who underwent endovascular thrombectomy in our center from January 2015 to December 2020. Imaging data were scored by 2‐physician consensus. We defined MeVO as occlusion beyond and including M2–middle cerebral artery, A2–anterior cerebral artery, or P2–posterior cerebral artery segments. Successful reperfusion was defined as Thrombolysis in Cerebral ischemia grades (≥2b/3). The primary outcome was patient home time (the number of nights a patient is back at their premorbid living situation without an increase in level of care within 90 days of the stroke) using random forest regression. Covariate contribution to home time was determined using partial dependence plots.\u0000 \u0000 \u0000 \u0000 Among 663 patients who underwent endovascular thrombectomy, 139 (20.9%) had MeVO (median age, 71 years; 50.4% women; median National Institutes of Health Stroke Scale, 16). The majority (82%) had good pial collaterals, 10.4% had a tandem extracranial carotid occlusion or stenosis, and 41.7% received intravenous thrombolysis. The most common site of occlusion was M2–middle cerebral artery (58.3%). One hundred eighteen (86.7%) patients achieved successful reperfusion (Thrombolysis in Cerebral Ischemia grades ≥2b/3). Using partial dependence plots, the mean predicted home times were similar in patients with MeVO (45.5 days) versus large‐vessel occlusions (44.6 days). Factors predicting lower 90‐day home time in patients with MeVOs were diabetes (−8.7 days), hypertension (−6.5 days), and atrial fibrillation (−3.5 days). There was no meaningful difference in predicted 90‐day home‐time by sex, baseline National Institutes of Health Stroke Scale, collateral grade, or thrombolysis.\u0000 \u0000 \u0000 \u0000 Patients with MeVO who are selected for endovascular therapy with similar demographic and clinical profiles to large‐vessel occlusions can achieve similar 90‐day home time outcomes to large‐vessel occlusions.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47739786","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}
P. Dhillon, Waleed Z. Butt, T. Jovin, A. Podlasek, N. McConachie, R. Lenthall, S. Nair, Luqman Malik, K. Krishnan, R. Dineen, T. England
The safety and efficacy of endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to large vessel occlusion presenting beyond 24 hours from last known well (LKW) remains undetermined. In this single center study, we identified patients with large vessel occlusion who were eligible for EVT based on noncontrast computed tomography (CT)/CT angiography (without CT perfusion or magnetic resonance imaging) using an Alberta Stroke Program Early CT Score of ≥5, National Institutes of Health Stroke Scale of ≥6, and presenting beyond 24 hours from LKW, between January 2018 and March 2022. During the study period, EVT service limitations meant patients eligible for EVT presenting outside service hours, routinely received best medical management (BMM). Functional and safety outcomes were compared between patients receiving EVT or BMM following multivariable adjustment for age, baseline stroke severity, Alberta Stroke Program Early CT Score, time from LKW, IV thrombolysis, and clot location. Among 35 patients presenting beyond 24 hours from LKW and eligible for EVT, 19 (54%) were treated with EVT and 16 (46%) with BMM. Alberta Stroke Program Early CT Score were similar across both groups (EVT: 7 [6.75–8] versus BMM: 7 [6–8]), but not the baseline National Institutes of Health Stroke Scale (EVT: 17 [11–19.5] versus BMM: 20 [9.75–26]). No significant difference was observed between the EVT and BMM groups in the symptomatic intracranial hemorrhage (5.3% versus 0%; P =0.28) or mortality (26.3% versus 37.5%; P =0.42) rates, respectively. The modified Rankin scale at 90 days (adjusted common odds ratio [OR], 1.94; [95% CI 0.42–8.87]; P =0.39) and functional independence rate, although numerically higher in the EVT group compared with the BMM group (modified Rankin scale≤2; 36.9% versus 18.8%; adjusted OR, 4.34; [95% CI 0.34–54.83]; P =0.25), were not significantly different. 94.7% of patients treated with EVT achieved successful reperfusion (modified thrombolysis in cerebral infarction 2b–3). In routine clinical practice, EVT beyond 24 hours from LKW appears safe and feasible, when performed in patients with acute ischemic stroke who were deemed eligible for EVT by noncontrast CT /CT angiography alone. A large collaborative randomized trial assessing the efficacy of EVT beyond 24 hours is warranted. Our findings provide a basis for the sample size estimate for an adequately powered trial.
{"title":"Endovascular Thrombectomy Versus Best Medical Management Beyond 24 Hours From Last Known Well in Acute Ischemic Stroke Due to Large Vessel Occlusion","authors":"P. Dhillon, Waleed Z. Butt, T. Jovin, A. Podlasek, N. McConachie, R. Lenthall, S. Nair, Luqman Malik, K. Krishnan, R. Dineen, T. England","doi":"10.1161/svin.122.000790","DOIUrl":"https://doi.org/10.1161/svin.122.000790","url":null,"abstract":"\u0000 \u0000 The safety and efficacy of endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to large vessel occlusion presenting beyond 24 hours from last known well (LKW) remains undetermined.\u0000 \u0000 \u0000 \u0000 In this single center study, we identified patients with large vessel occlusion who were eligible for EVT based on noncontrast computed tomography (CT)/CT angiography (without CT perfusion or magnetic resonance imaging) using an Alberta Stroke Program Early CT Score of ≥5, National Institutes of Health Stroke Scale of ≥6, and presenting beyond 24 hours from LKW, between January 2018 and March 2022. During the study period, EVT service limitations meant patients eligible for EVT presenting outside service hours, routinely received best medical management (BMM). Functional and safety outcomes were compared between patients receiving EVT or BMM following multivariable adjustment for age, baseline stroke severity, Alberta Stroke Program Early CT Score, time from LKW, IV thrombolysis, and clot location.\u0000 \u0000 \u0000 \u0000 \u0000 Among 35 patients presenting beyond 24 hours from LKW and eligible for EVT, 19 (54%) were treated with EVT and 16 (46%) with BMM. Alberta Stroke Program Early CT Score were similar across both groups (EVT: 7 [6.75–8] versus BMM: 7 [6–8]), but not the baseline National Institutes of Health Stroke Scale (EVT: 17 [11–19.5] versus BMM: 20 [9.75–26]). No significant difference was observed between the EVT and BMM groups in the symptomatic intracranial hemorrhage (5.3% versus 0%;\u0000 P\u0000 =0.28) or mortality (26.3% versus 37.5%;\u0000 P\u0000 =0.42) rates, respectively. The modified Rankin scale at 90 days (adjusted common odds ratio [OR], 1.94; [95% CI 0.42–8.87];\u0000 P\u0000 =0.39) and functional independence rate, although numerically higher in the EVT group compared with the BMM group (modified Rankin scale≤2; 36.9% versus 18.8%; adjusted OR, 4.34; [95% CI 0.34–54.83];\u0000 P\u0000 =0.25), were not significantly different. 94.7% of patients treated with EVT achieved successful reperfusion (modified thrombolysis in cerebral infarction 2b–3).\u0000 \u0000 \u0000 \u0000 \u0000 In routine clinical practice, EVT beyond 24 hours from LKW appears safe and feasible, when performed in patients with acute ischemic stroke who were deemed eligible for EVT by noncontrast CT /CT angiography alone. A large collaborative randomized trial assessing the efficacy of EVT beyond 24 hours is warranted. Our findings provide a basis for the sample size estimate for an adequately powered trial.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47043498","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}
P. M. Janssen, B. Roozenbeek, J. Coutinho, A. V. van Es, W. Schonewille, G. Lycklama à Nijeholt, Hester F. Lingsma, D. Dippel
Insight in the effect of workflow improvements can help to minimize the time between onset of ischemic stroke and start of endovascular thrombectomy (EVT). The authors aimed to assess the implementation of EVT workflow strategies and their effect on time to treatment. The authors used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) registry and included patients with acute ischemic stroke in the anterior circulation, who underwent EVT between March 2014 and November 2017. Data on implementation of 20 predefined workflow improvement strategies during the study period were collected from each intervention center. Multilevel linear regression with a random intercept for center was used to quantify the effect of each strategy on door‐to‐groin puncture time, with adjustment for calendar time, for directly presented and transferred patients separately. The authors included 2633 patients who were treated in 14 intervention centers. Of the 20 predefined strategies, 18 were actually implemented in ≥1 centers during the study period. In directly presented patients (n=1157), the intervention with the largest effect on door‐to‐groin puncture time was a strategy to avoid sedation during EVT compared with standard use of general anesthesia, which led to a reduction of 29% (95% CI, 6–46; P =0.02), corresponding to a decrease of 26 minutes (95% CI, 5–42). In transferred patients (n=1476), the interventions with the largest decrease in door‐to‐groin puncture time were a strategy to make the decision for patient transfer to the angiosuite after 1 stroke physician assessed the imaging, instead of both interventionist and neurologist (47% [95% CI, 5–70]; 19 minutes [95% CI, 2–29]) ( P =0.03), and a strategy to perform neurological assessment at the angiosuite instead of the emergency department (32% [95% CI, 19–43]; 13 minutes [95% CI, 8–17]) ( P <0.001). Intervention centers have implemented multiple new strategies to improve their workflow. Such workflow improvements lead to substantial reductions in time to EVT and may thereby improve the outcome of patients with acute ischemic stroke.
{"title":"Effect of Workflow Improvements on Time to Endovascular Thrombectomy for Acute Ischemic Stroke in the MR CLEAN Registry","authors":"P. M. Janssen, B. Roozenbeek, J. Coutinho, A. V. van Es, W. Schonewille, G. Lycklama à Nijeholt, Hester F. Lingsma, D. Dippel","doi":"10.1161/svin.122.000733","DOIUrl":"https://doi.org/10.1161/svin.122.000733","url":null,"abstract":"\u0000 \u0000 Insight in the effect of workflow improvements can help to minimize the time between onset of ischemic stroke and start of endovascular thrombectomy (EVT). The authors aimed to assess the implementation of EVT workflow strategies and their effect on time to treatment.\u0000 \u0000 \u0000 \u0000 The authors used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) registry and included patients with acute ischemic stroke in the anterior circulation, who underwent EVT between March 2014 and November 2017. Data on implementation of 20 predefined workflow improvement strategies during the study period were collected from each intervention center. Multilevel linear regression with a random intercept for center was used to quantify the effect of each strategy on door‐to‐groin puncture time, with adjustment for calendar time, for directly presented and transferred patients separately.\u0000 \u0000 \u0000 \u0000 \u0000 The authors included 2633 patients who were treated in 14 intervention centers. Of the 20 predefined strategies, 18 were actually implemented in ≥1 centers during the study period. In directly presented patients (n=1157), the intervention with the largest effect on door‐to‐groin puncture time was a strategy to avoid sedation during EVT compared with standard use of general anesthesia, which led to a reduction of 29% (95% CI, 6–46;\u0000 P\u0000 =0.02), corresponding to a decrease of 26 minutes (95% CI, 5–42). In transferred patients (n=1476), the interventions with the largest decrease in door‐to‐groin puncture time were a strategy to make the decision for patient transfer to the angiosuite after 1 stroke physician assessed the imaging, instead of both interventionist and neurologist (47% [95% CI, 5–70]; 19 minutes [95% CI, 2–29]) (\u0000 P\u0000 =0.03), and a strategy to perform neurological assessment at the angiosuite instead of the emergency department (32% [95% CI, 19–43]; 13 minutes [95% CI, 8–17]) (\u0000 P\u0000 <0.001).\u0000 \u0000 \u0000 \u0000 \u0000 Intervention centers have implemented multiple new strategies to improve their workflow. Such workflow improvements lead to substantial reductions in time to EVT and may thereby improve the outcome of patients with acute ischemic stroke.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44274398","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}
P. Dhillon, Emma Soo, Waleed Z. Butt, Thanh N. Nguyen, E. Barrett, A. Podlasek, N. McConachie, R. Lenthall, S. Nair, Luqman Malik, Chesvin Cheema, P. Bhogal, H. Makalanda, M. James, R. Dineen, T. England
Patients with acute ischemic stroke onset during hospital admission often have concurrent illnesses, increased underlying comorbidities and are often associated with a delayed recognition of stroke onset, compared with patients with stroke onset in the community (community‐onset stroke [COS]). Endovascular thrombectomy (EVT) for large‐vessel occlusion in acute ischemic stroke has been proven to be effective, though the safety and feasibility of EVT among patients with in‐hospital stroke (IHS) onset remains undetermined. We aim to compare the workflow and clinical outcomes for patients undergoing EVT following IHS onset and COS. Using data from a national stroke registry, we used propensity score‐matched individual‐level data of patients who underwent EVT, following IHS and COS, between October 2015 and March 2020. Univariate analysis was performed to assess the procedural, functional, and safety outcomes. We included 4353 patients (COS, 4104 [249 after propensity score matching]; IHS, 249 [249 after propensity score matching]). Compared with COS, patients with IHS had similar modified Rankin Scale on discharge (odds ratio [OR], 0.98 [95% CI, 0.72–1.34]; P =0.96) and at 6 months (OR, 1.25 [95% CI, 0.71–2.24]; P =0.48). No significant difference in achieving good functional outcome (modified Rankin Scale ≤ 2 at discharge; 31.3% [IHS] versus 29.3% [COS]; OR,=1.10 [95% CI 0.74–1.60]; P =0.61), successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b–3), P =0.82; or safety outcomes of symptomatic intracranial hemorrhage ( P =0.64) and in‐hospital mortality ( P =0.26) were demonstrated. Shorter time interval from stroke onset to imaging in the IHS group (IHS, 80±88 versus COS, 216±292 minutes) was observed. The imaging‐to‐arterial‐puncture time was not significantly different between the groups (IHS, 160±140 versus COS, 162±184 minutes; P =0.85). EVT in patients with IHS is safe and feasible, with comparable functional and safety outcomes to patients with COS, in this national stroke registry. Continued efforts are required to improve the inpatient stroke workflow in recognizing stroke symptoms and initiating reperfusion treatment for eligible patients with IHS.
{"title":"Comparison Between In‐Hospital and Community‐Onset Stroke Treated With Endovascular Thrombectomy: A Propensity Score–Matched Cohort Study","authors":"P. Dhillon, Emma Soo, Waleed Z. Butt, Thanh N. Nguyen, E. Barrett, A. Podlasek, N. McConachie, R. Lenthall, S. Nair, Luqman Malik, Chesvin Cheema, P. Bhogal, H. Makalanda, M. James, R. Dineen, T. England","doi":"10.1161/svin.122.000816","DOIUrl":"https://doi.org/10.1161/svin.122.000816","url":null,"abstract":"\u0000 \u0000 Patients with acute ischemic stroke onset during hospital admission often have concurrent illnesses, increased underlying comorbidities and are often associated with a delayed recognition of stroke onset, compared with patients with stroke onset in the community (community‐onset stroke [COS]). Endovascular thrombectomy (EVT) for large‐vessel occlusion in acute ischemic stroke has been proven to be effective, though the safety and feasibility of EVT among patients with in‐hospital stroke (IHS) onset remains undetermined. We aim to compare the workflow and clinical outcomes for patients undergoing EVT following IHS onset and COS.\u0000 \u0000 \u0000 \u0000 Using data from a national stroke registry, we used propensity score‐matched individual‐level data of patients who underwent EVT, following IHS and COS, between October 2015 and March 2020. Univariate analysis was performed to assess the procedural, functional, and safety outcomes.\u0000 \u0000 \u0000 \u0000 \u0000 We included 4353 patients (COS, 4104 [249 after propensity score matching]; IHS, 249 [249 after propensity score matching]). Compared with COS, patients with IHS had similar modified Rankin Scale on discharge (odds ratio [OR], 0.98 [95% CI, 0.72–1.34];\u0000 P\u0000 =0.96) and at 6 months (OR, 1.25 [95% CI, 0.71–2.24];\u0000 P\u0000 =0.48). No significant difference in achieving good functional outcome (modified Rankin Scale ≤ 2 at discharge; 31.3% [IHS] versus 29.3% [COS]; OR,=1.10 [95% CI 0.74–1.60];\u0000 P\u0000 =0.61), successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b–3),\u0000 P\u0000 =0.82; or safety outcomes of symptomatic intracranial hemorrhage (\u0000 P\u0000 =0.64) and in‐hospital mortality (\u0000 P\u0000 =0.26) were demonstrated. Shorter time interval from stroke onset to imaging in the IHS group (IHS, 80±88 versus COS, 216±292 minutes) was observed. The imaging‐to‐arterial‐puncture time was not significantly different between the groups (IHS, 160±140 versus COS, 162±184 minutes;\u0000 P\u0000 =0.85).\u0000 \u0000 \u0000 \u0000 \u0000 EVT in patients with IHS is safe and feasible, with comparable functional and safety outcomes to patients with COS, in this national stroke registry. Continued efforts are required to improve the inpatient stroke workflow in recognizing stroke symptoms and initiating reperfusion treatment for eligible patients with IHS.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48119778","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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