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1.
Neurosurg Focus ; 56(3): E5, 2024 03.
Artigo em Inglês | MEDLINE | ID: mdl-38427986

RESUMO

OBJECTIVE: Endovascular treatment (EVT) is the primary approach used to treat indirect carotid-cavernous fistulas (CCFs). In this study, the authors evaluated the immediate and long-term efficacy and safety of different endovascular techniques for indirect CCFs. METHODS: The databases of two endovascular centers were retrospectively reviewed to collect the patients with indirect CCFs treated using endovascular techniques between 2013 and 2023. Demographics, clinical presentation, CCF features, EVT characteristics, and clinical and radiological outcomes were evaluated and analyzed. The analysis was performed to compare the clinical and radiological data between different endovascular approaches and different embolic materials. RESULTS: Ninety-eight patients were included in the study. EVT was successful in 95 patients (96.9%). Immediate complete obliteration of the CCF was achieved in 93.9% of patients, with 98% undergoing embolization with liquid embolic agents (LEAs) and 95.6% undergoing coiling alone. Complete CCF obliteration was higher in the transvenous than in the transarterial approach (94.3% vs 75%, p = 0.010). At ≥ 6 months follow-up, complete CCF obliteration was achieved in all patients (100%). The rate of procedure-related complications was higher following LEAs than with coiling alone (32.0% vs 15.6%). New cranial nerve (CN) palsy was diagnosed in 26.0% and 2.2% after embolization with LEAs and coiling alone, respectively (p = 0.001), with complete CN palsy recovery in 78.6%. Procedure-related intracranial hemorrhage occurred in 3 patients (3.1%). Two patients experienced an ischemic stroke following Onyx migration into the internal carotid artery. Ocular symptoms improved in 93% (83/89) of the patients who were followed. CONCLUSIONS: In this study, complete obliteration of an indirect CCF was achieved in more than 90% of patients. Despite the occurrence of some new postprocedural ocular CN palsy, ocular symptoms improved in most patients in long-term follow-up. The transvenous approach was the most effective method for treating the indirect CCF. Coiling was safer than LEAs for the embolization of the indirect CCF.


Assuntos
Fístula Carótido-Cavernosa , Embolização Terapêutica , Procedimentos Endovasculares , Humanos , Fístula Carótido-Cavernosa/diagnóstico por imagem , Fístula Carótido-Cavernosa/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Paralisia/complicações , Paralisia/terapia
2.
Stroke ; 53(3): 719-727, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-35109685

RESUMO

BACKGROUND AND PURPOSE: To assess the association between systolic blood pressure change (ΔSBP) at different time intervals after successful reperfusion with radiographic and clinical outcomes. METHODS: This is a post hoc analysis of the BP-TARGET multicenter trial (Blood Pressure Target in Acute Stroke to Reduce Hemorrhage After Endovascular Therapy). ΔSBP was defined as end of procedure SBP minus mean SBP at different time intervals (15-60 minutes, 1-6 hours, and 6-24 hours postprocedure). The primary outcome was the poor functional outcome (90-day modified Rankin Scale score 3-6). RESULTS: We included a total of 267 patients (130 in the intensive treatment group). Compared with patients with favorable outcome, patients with poor outcome had lower ΔSBP (less SBP reduction) at all times intervals. After adjusting for potential confounders including baseline SBP, both ΔSBP15-60M and ΔSBP6-24H were associated with lower odds of poor outcome (adjusted odds ratio per 5 mm Hg SBP reduction, 0.89 [95% CI, 0.81-0.99], and adjusted odds ratio 0.82 [95% CI, 0.73-0.92], respectively). Concerning safety outcomes, patients with intraparenchymal hemorrhage had lower ΔSBP at all time intervals. ΔSBP15-60M was associated with lower odds of any intraparenchymal hemorrhage (adjusted odds ratio per 5 mm Hg SBP reduction 0.91 [95% CI, 0.83-0.99]). Conversely, ΔSBP was not associated with mortality or neurological deterioration at any time interval. CONCLUSIONS: After successful reperfusion, ΔSBP had a linear relationship with poor outcome and the risk of poor outcome was higher with less reduction from the baseline SBP. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03160677.


Assuntos
Pressão Sanguínea , Hemorragia Cerebral , Procedimentos Endovasculares , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/genética , Hemorragia Cerebral/fisiopatologia , Hemorragia Cerebral/prevenção & controle , Feminino , Humanos , Masculino , Reperfusão , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/terapia
3.
Eur J Neurol ; 29(3): 771-781, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-34821437

RESUMO

BACKGROUND AND PURPOSE: The Blood Pressure Target in Acute Ischemic Stroke to Reduce Hemorrhage After Endovascular Therapy (BP TARGET) trial evaluated whether an intensive systolic blood pressure (SBP) target resulted in reduced rates of intracranial hemorrhage (ICH) after successful endovascular therapy (EVT) but did not assess the effect of blood pressure variability (BPV) on functional outcomes and ICH occurrence. We sought to evaluate this question in the BP TARGET trial. METHODS: We performed a post hoc analysis of the BP TARGET trial and included patients with at least 50% of blood pressure (BP) recordings during the first 24 h after EVT. BPV parameters were SBP and diastolic BP (DBP) coefficient of variation (CV), standard deviation (SD), maximum-minimum (max-min), successive variation (SV), and time rate. The primary outcome was favorable functional outcome (3-month modified Rankin Scale between 0 and 2); the secondary outcome was the rate of ICH at 24 h. RESULTS: We included 290 patients (mean number of BP measures = 30.4, SD = 8.0). BPV parameters (SBPSD , SBPmax-min , SBPCV ) were higher in the intensive SBP target group. Only DBP BPV parameters were associated with worse functional outcomes in the unadjusted model (DBPSD , DBPmax-min , DBPCV , and DBPSV ), but not after adjustment. Higher SBPmax-min was associated with worse functional outcomes in Thrombolysis in Cerebral Infarction 2B patients (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.38-1.02), but not in patients with complete reperfusion (OR = 1.27, 95% CI = 0.80-2.02, p for heterogeneity (phet =0.037). None of the BPV parameters was associated with ICH, regardless of the randomization group or the reperfusion grade. CONCLUSIONS: BPV was significantly higher in the intensive SBP target group but was not associated with functional outcome or ICH.


Assuntos
AVC Isquêmico , Acidente Vascular Cerebral , Pressão Sanguínea/fisiologia , Infarto Cerebral , Humanos , Hemorragias Intracranianas , Razão de Chances , Resultado do Tratamento
4.
Eur J Neurol ; 29(11): 3273-3287, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-35818781

RESUMO

BACKGROUND AND PURPOSE: Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. METHODS: A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted. RESULTS: In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001). CONCLUSION: COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.


Assuntos
Isquemia Encefálica , COVID-19 , Procedimentos Endovasculares , Acidente Vascular Cerebral , COVID-19/complicações , Estudos Transversais , Procedimentos Endovasculares/métodos , Humanos , Masculino , Estudos Retrospectivos , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Resultado do Tratamento
5.
Neuroradiology ; 64(5): 1037-1042, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35199209

RESUMO

To report the occurrence of non-ischemic cerebral enhancing (NICE) lesions following mechanical thrombectomy (MT) through the retrospective French nationwide registry of NICE lesions. All thrombectomy capable stroke centers (TSC) in France were invited to fill out a questionnaire disseminated through a trainee-led research network (JENI-RC: Jeunes en Neuroradiologie Interventionnelle-Research Collaborative). NICE lesions were defined according to previous literature as delayed onset punctate, nodular, or annular foci enhancements with peri-lesion edema and vascular distribution in the territory of the MT with no other confounding disease. All 43 TSC French centers responded. Three patients were reported by 3 different centers over a total of 34,824 MT (2015-2020). Patient no. 1 developed symptomatic NICE lesions 8 weeks after MT with combination of aspiration and stentriever for a right middle cerebral artery occlusion. Patient no. 2 developed asymptomatic NICE lesions 5 weeks after MT with direct thromboaspiration for a right middle cerebral artery occlusion. Patient no. 3 developed symptomatic NICE lesions 6 weeks after MT with direct thromboaspiration, and combination of aspiration and stentriever for a basilar artery occlusion. This study provides evidence that NICE lesions following MT are a possible rare complication with a similar presentation as previously described following endovascular aneurysm treatment. Both radiologists and neurologists should be aware of this adverse event and make use of MRI contrast agents in case of unexplained symptoms/images during follow-up after MT.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Isquemia Encefálica , Procedimentos Endovasculares , Acidente Vascular Cerebral , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Humanos , Infarto da Artéria Cerebral Média , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Resultado do Tratamento
6.
Platelets ; 33(2): 285-290, 2022 Feb 17.
Artigo em Inglês | MEDLINE | ID: mdl-33840346

RESUMO

Immediate reocclusion after mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is a rare but devastating condition associated with poor functional outcome. The aim of this study was to gain insights into the mechanisms underlying immediate reocclusion, and to evaluate the efficacy and safety of the glycoprotein IIb/IIIa antagonist abciximab, for its treatment. Clinical data were collected from April 2015 to April 2019 in a monocentric prospective registry of AIS patients treated by MT. All patients with immediate reocclusion were retrospectively selected and subdivided into 2 groups according to abciximab treatment status. In vitro, the separate and combined effects of abciximab and alteplase on clot formation in whole blood under flow conditions were further investigated in microfluidic chambers. From 929 MT-treated patients, 21 had post-MT immediate reocclusion. Abciximab treatment in reocclusion patients (n = 10) led to higher rate of final recanalization (p < .001) while it did not increase bleeding complications. Flow chamber experiments revealed that, in contrast to alteplase, abciximab efficiently limits thrombus accretion from flowing blood by blocking platelet aggregation. Our results underscore a key role for platelet aggregation and the potential of Glycoprotein IIb/IIIa antagonists as a rescue therapy in post-MT immediate reocclusion.


Assuntos
Abciximab/uso terapêutico , Administração Intravenosa/métodos , AVC Isquêmico/tratamento farmacológico , AVC Isquêmico/cirurgia , Inibidores da Agregação Plaquetária/uso terapêutico , Trombectomia/métodos , Abciximab/farmacologia , Doença Aguda , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/farmacologia
7.
Stroke ; 52(9): 2964-2967, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34134507

RESUMO

BACKGROUND AND PURPOSE: Hypotension during endovascular therapy for acute ischemic stroke is associated with worse functional outcomes (FO). Given its important role in intracranial hemodynamics, we investigated whether hypotension during endovascular therapy had the same effect on FO according to the posterior communicating artery (PComA) patency. METHODS: We performed a post hoc analysis of the ASTER trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization). Patients were included if they had middle cerebral artery occlusions. Primary outcome was favorable FO, defined by a modified Rankin Scale scores between 0 and 2 at 3 months. RESULTS: One hundred forty-eight patients with middle cerebral artery occlusion were included. In patients with no PComA, an increase in minimum mean arterial pressure was positively associated with favorable FO (odds ratio per 10 mm Hg increase, 1.59 [95%CI, 1.11-2.25]; P=0.010), whereas no association was found in patients with a PComA (odds ratio, 0.77 [95% CI, 0.54-1.08]; P=0.12). Patients with no PComA and longer cumulative time with mean arterial pressure <90 mm Hg or systolic blood pressure <140 mm Hg had significantly lower rates of favorable FO, with an odds ratio per 10-minute increase of 0.75 (95% CI, 0.59-0.94; P=0.010) and 0.74 (95% CI, 0.60-0.91; P=0.003), but not in patients with a PComA. CONCLUSIONS: Hypotension during endovascular therapy for middle cerebral artery occlusion is consistently associated with worse FO in patients with no PComA but not in those with a PComA. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02523261.


Assuntos
Isquemia Encefálica/cirurgia , Hipotensão/cirurgia , AVC Isquêmico/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia , Pressão Sanguínea/fisiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Humanos , Trombectomia/efeitos adversos , Resultado do Tratamento
8.
Stroke ; 52(9): 2736-2742, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34233462

RESUMO

BACKGROUND AND PURPOSE: We aimed to evaluate among trained interventional neuroradiologist, whether increasing individual experience was associated with an improvement in mechanical thrombectomy (MT) procedural performance metrics. METHODS: Individual MT procedural data from 5 centers of the Endovascular Treatment in Ischemic Stroke registry and 2 additional high-volume stroke centers were pooled. Operator experience was defined for each operator as a continuous variable, cumulating the number of MT procedures performed since January 2015, as MT became standard of care or, if later than this date, since the operator started performing mechanical thrombectomies in autonomy. We tested the associations between operator's experience and procedural metrics. RESULTS: A total of 4516 procedures were included, performed by 36 operators at 7 distinct centers, with a median of 97.5 endovascular treatment procedures per operator (interquartile range, 57-170.2) over the study period. Higher operator's experience, analyzed as a continuous variable, was associated with a significantly shorter procedural duration (ß estimate, -3.98 [95% CI, -5.1 to -2.8]; P<0.001), along with local anesthesia and M1 occlusion location in multivariable models. Increasing experience was associated with better Thrombolysis in Cerebral Infarction scores (estimate, 1.02 [1-1.04]; P=0.013). CONCLUSIONS: In trained interventional neuroradiologists, increasing experience in MT is associated with significantly shorter procedural duration and better reperfusion rates, with a theoretical ceiling effect observed after around 100 procedures. These results may inform future training and practice guidelines to set minimal experience standards before autonomization, and to set-up operators' recertification processes tailored to individual case volume and prior experience.


Assuntos
Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Cirurgiões , Trombectomia , Infarto Cerebral/complicações , Infarto Cerebral/cirurgia , Procedimentos Endovasculares/métodos , Humanos , Sistema de Registros , Reperfusão/métodos , Trombectomia/métodos , Fatores de Tempo
9.
Stroke ; 52(1): 31-39, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33222617

RESUMO

BACKGROUND AND PURPOSE: Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19. METHODS: Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality. SECONDARY OUTCOMES: early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0-1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage. RESULTS: We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59-79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11-21) and 8 (interquartile range, 7-9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3-87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20-39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8-29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7-12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21-5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22-5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43-12.91] per SD-log increase in LDH). CONCLUSIONS: The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient's profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04406090.


Assuntos
COVID-19/complicações , Procedimentos Endovasculares , AVC Isquêmico/complicações , AVC Isquêmico/cirurgia , Trombectomia , Idoso , Idoso de 80 Anos ou mais , COVID-19/epidemiologia , Estudos de Coortes , Procedimentos Endovasculares/mortalidade , Europa (Continente) , Feminino , Humanos , AVC Isquêmico/mortalidade , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , SARS-CoV-2 , Trombectomia/mortalidade , Resultado do Tratamento
10.
J Stroke Cerebrovasc Dis ; 30(2): 105521, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33310073

RESUMO

INTRODUCTION: Guidelines for antiplatelet therapy administration, during emergent stenting for extra-cranial internal carotid artery (EC-ICA) occlusion in the setting of acute ischemic stroke (AIS) are lacking. Different antiplatelet regimen are used in association to endovascular therapy (EVT) for the treatment of EC-ICA lesions. We aimed to compare the clinical and radiological effects of three intravenous antiplatelet agents used during emergent EC-ICA stenting. MATERIAL AND METHODS: Clinical data were collected from January 2015 to December 2019 in a monocentric prospective registry of AIS patients treated by EVT. All patients who underwent emergent EC-ICA stenting were sorted regarding the intravenous antiplatelet agent used during the procedure. RESULTS: Among 218 patients treated by EVT for an EC-ICA occlusion of the anterior circulation during the study period, 70 underwent an emergent stenting of the EC-ICA. 60 were included in the present study, 9 received intravenous (IV) Cangrelor, 8 IV abciximab and 43 Aspirin. The rate of favorable neurological outcome, defined as modified Rankin Scale (mRS) ≤ 2 at three months were better in the Cangrelor and Aspirin groups (66,7% and 58,1%, respectively) than in the Abciximab group (37,5%), as well as, the rate of any intracranial ICH (22,2% and 37,2% vs 62,5%). The rate of acute stent reocclusion was similar between groups. CONCLUSION: When used as a rescue treatment during emergent stenting of EC-ICA, Cangrelor and Aspirin present a better safety profile than Abciximab, with less intracranial hemorrhages and a higher rate of good clinical outcome. Additional studies are needed to confirm these findings.


Assuntos
Artéria Carótida Interna , Estenose das Carótidas/terapia , Procedimentos Endovasculares/instrumentação , AVC Isquêmico/tratamento farmacológico , Inibidores da Agregação Plaquetária/administração & dosagem , Stents , Abciximab/administração & dosagem , Monofosfato de Adenosina/administração & dosagem , Monofosfato de Adenosina/análogos & derivados , Administração Intravenosa , Idoso , Aspirina/administração & dosagem , Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Esquema de Medicação , Emergências , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , AVC Isquêmico/complicações , AVC Isquêmico/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/efeitos adversos , Sistema de Registros , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
11.
Stroke ; 51(11): 3366-3370, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32813602

RESUMO

BACKGROUND AND PURPOSE: Reports are emerging regarding the association of acute ischemic strokes with large vessel occlusion and coronavirus disease 2019 (COVID-19). While a higher severity of these patients could be expected from the addition of both respiratory and neurological injury, COVID-19 patients with strokes can present with mild or none respiratory symptoms. We aimed to compare anterior circulation large vessel occlusion strokes severity between patients with and without COVID-19. METHODS: We performed a comparative cohort study between patients with COVID-19 who had anterior circulation large vessel occlusion and early brain imaging within 3 hours from onset, in our institution during the 6 first weeks of the COVID-19 outbreak and a control group admitted during the same calendar period in 2019. RESULTS: Twelve COVID-19 patients with anterior circulation large vessel occlusion and early brain imaging were included during the study period and compared with 34 control patients with anterior circulation large vessel occlusion and early brain imaging in 2019. Patients in the COVID-19 group were younger (P=0.032) and had a history of diabetes mellitus more frequently (P=0.039). Patients did not significantly differ on initial National Institutes of Health Stroke Scale nor time from onset to imaging (P=0.18 and P=0.6, respectively). Patients with COVID-19 had more severe strokes than patients without COVID-19, with a significantly lower clot burden score (median: 6.5 versus 8, P=0.016), higher rate of multivessel occlusion (50% versus 8.8%, P=0.005), lower DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Scores; median: 5 versus 8, P=0.006), and higher infarct core volume (median: 58 versus 6 mL, P=0.004). Successful recanalization rate was similar in both groups (P=0.767). In-hospital mortality was higher in the COVID-19 patients' group (41.7% versus 11.8%, P=0.025). CONCLUSIONS: Early brain imaging showed higher severity large vessel occlusion strokes in patients with COVID-19. Given the massive number of infected patients, concerns should be raised about the coming neurovascular impact of the pandemic worldwide.


Assuntos
Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , COVID-19 , Estudos de Casos e Controles , Angiografia Cerebral , Angiografia por Tomografia Computadorizada , Imagem de Difusão por Ressonância Magnética , Feminino , Mortalidade Hospitalar , Humanos , Infarto da Artéria Cerebral Anterior/complicações , Infarto da Artéria Cerebral Anterior/diagnóstico por imagem , Infarto da Artéria Cerebral Anterior/fisiopatologia , Infarto da Artéria Cerebral Anterior/terapia , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/fisiopatologia , Infarto da Artéria Cerebral Média/terapia , Infarto da Artéria Cerebral Posterior/complicações , Infarto da Artéria Cerebral Posterior/diagnóstico por imagem , Infarto da Artéria Cerebral Posterior/fisiopatologia , Infarto da Artéria Cerebral Posterior/terapia , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Pandemias , SARS-CoV-2 , Índice de Gravidade de Doença , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica
12.
Stroke ; 51(8): 2540-2543, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32466736

RESUMO

BACKGROUND AND PURPOSE: Higher rates of strokes have been observed in patients with coronavirus disease 2019 (COVID-19), but data regarding the outcomes of COVID-19 patients suffering from acute ischemic stroke due to large vessel occlusion (LVO) are lacking. We report our initial experience in the treatment of acute ischemic stroke with LVO in patients with COVID-19. METHODS: All consecutive patients with COVID-19 with acute ischemic stroke due to LVO treated in our institution during the 6 first weeks of the COVID-19 outbreak were included. Baseline clinical and radiological findings, treatment, and short-term outcomes are reported. RESULTS: We identified 10 patients with confirmed COVID-19 treated for an acute ischemic stroke due to LVO. Eight were men, with a median age of 59.5 years. Seven had none or mild symptoms of COVID-19 at stroke onset. Median time from COVID-19 symptoms to stroke onset was 6 days. All patients had brain imaging within 3 hours from symptoms onset. Five patients had multi-territory LVO. Five received intravenous alteplase. All patients had mechanical thrombectomy. Nine patients achieved successful recanalization (mTICI2B-3), none experienced early neurological improvement, 4 had early cerebral reocclusion, and a total of 6 patients (60%) died in the hospital. CONCLUSIONS: Best medical care including early intravenous thrombolysis, and successful and prompt recanalization achieved with mechanical thrombectomy, resulted in poor outcomes in patients with COVID-19. Although our results require further confirmation, a different pharmacological approach (antiplatelet or other) should be investigated to take in account inflammatory and coagulation disorders associated with COVID-19.


Assuntos
Arteriopatias Oclusivas/complicações , Isquemia Encefálica/etiologia , Isquemia Encefálica/terapia , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia , Idoso , Arteriopatias Oclusivas/diagnóstico por imagem , Transtornos da Coagulação Sanguínea/etiologia , Encéfalo/diagnóstico por imagem , Isquemia Encefálica/diagnóstico por imagem , COVID-19 , Artérias Cerebrais , Veias Cerebrais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Ativadores de Plasminogênio/uso terapêutico , Acidente Vascular Cerebral/diagnóstico por imagem , Trombectomia , Terapia Trombolítica , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
13.
Stroke ; 51(4): 1199-1206, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32156204

RESUMO

Background and Purpose- Guidelines regarding blood pressure (BP) management during endovascular therapy (EVT) for anterior circulation strokes are questionable since the optimal BP target is a matter of debate. To evaluate the importance of hemodynamic control during EVT, we investigated the impact of dynamic and steady BP parameters during EVT on functional outcome (part 1) and according to the collateral status (CS; part 2). Methods- We performed a post hoc analysis of the ASTER trial (Contact Aspiration Versus Stent Retriever for Successful Recanalization). BP was measured noninvasively during EVT and CS assessed on the angiographic run before EVT. We studied dynamic BP parameter using BP variability (coefficient of variation) and steady BP parameter (hypotension time defined as systolic BP <140 mm Hg and mean arterial pressure <90 mm Hg). The primary outcome was favorable outcome defined as a 3-month modified Rankin Scale score between 0 and 2. Results- Among the 381 patients of the ASTER study, 172 patients were included in part 1 and 159 in part 2. Systolic BP, diastolic BP, and mean arterial pressure variability were negatively associated with favorable outcome regardless of CS: per 10-unit increase, adjusted odds ratios were 0.45 (95% CI, 0.20-0.98), 0.37 (95% CI, 0.19-0.72), and 0.35 (95% CI, 0.16-0.76), respectively. According to CS, the hypotension time with periprocedural mean arterial pressure <90 mm Hg was negatively associated with favorable outcome in patients with poor CS (adjusted odds ratio, 0.88 [95% CI, 0.72-1.09]) but not in patients with good CS (adjusted odds ratio, 1.24 [95% CI, 0.91-1.67]; Phet=0.047). Conclusions- The CS did not modify the association between dynamic parameters and functional outcomes, but some findings suggest that the CS modifies the association between steady parameter and functional outcomes. Hypotension time according to the CS was not statistically predictive of poor outcomes but displayed a trend toward worse outcomes for patients with poor CS only.


Assuntos
Determinação da Pressão Arterial/métodos , Pressão Sanguínea/fisiologia , Circulação Colateral/fisiologia , Monitorização Intraoperatória/métodos , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
14.
Stroke ; 51(7): 2012-2017, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32432994

RESUMO

BACKGROUND AND PURPOSE: The efficiency of prehospital care chain response and the adequacy of hospital resources are challenged amid the coronavirus disease 2019 (COVID-19) outbreak, with suspected consequences for patients with ischemic stroke eligible for mechanical thrombectomy (MT). METHODS: We conducted a prospective national-level data collection of patients treated with MT, ranging 45 days across epidemic containment measures instatement, and of patients treated during the same calendar period in 2019. The primary end point was the variation of patients receiving MT during the epidemic period. Secondary end points included care delays between onset, imaging, and groin puncture. To analyze the primary end point, we used a Poisson regression model. We then analyzed the correlation between the number of MTs and the number of COVID-19 cases hospitalizations, using the Pearson correlation coefficient (compared with the null value). RESULTS: A total of 1513 patients were included at 32 centers, in all French administrative regions. There was a 21% significant decrease (0.79; [95%CI, 0.76-0.82]; P<0.001) in MT case volumes during the epidemic period, and a significant increase in delays between imaging and groin puncture, overall (mean 144.9±SD 86.8 minutes versus 126.2±70.9; P<0.001 in 2019) and in transferred patients (mean 182.6±SD 82.0 minutes versus 153.25±67; P<0.001). After the instatement of strict epidemic mitigation measures, there was a significant negative correlation between the number of hospitalizations for COVID and the number of MT cases (R2 -0.51; P=0.04). Patients treated during the COVID outbreak were less likely to receive intravenous thrombolysis and to have unwitnessed strokes (both P<0.05). CONCLUSIONS: Our study showed a significant decrease in patients treated with MTs during the first stages of the COVID epidemic in France and alarming indicators of lengthened care delays. These findings prompt immediate consideration of local and regional stroke networks preparedness in the varying contexts of COVID-19 pandemic evolution.


Assuntos
Betacoronavirus , Isquemia Encefálica/cirurgia , Infecções por Coronavirus , Atenção à Saúde , Trombólise Mecânica/estatística & dados numéricos , Pandemias , Pneumonia Viral , Acidente Vascular Cerebral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , COVID-19 , Feminino , França/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Trombólise Mecânica/métodos , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Utilização de Procedimentos e Técnicas , Estudos Prospectivos , SARS-CoV-2 , Acidente Vascular Cerebral/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos
15.
Neuroradiology ; 62(10): 1341-1344, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32448996

RESUMO

Central vein disease (CVD) is a well-known complication of central venous cannulations, indwelling dialysis catheters, and arteriovenous grafts. Brachiocephalic vein (BCV) stenosis or thrombotic occlusion can occur in dialysis patients, and the presence of an ipsilateral arteriovenous fistula can cause cerebral venous hypertension due to retrograde flow in the ipsilateral jugular vein. A 53-year-old man receiving hemodialysis (left brachiocephalic hemodialysis fistula) presented with impaired consciousness and seizures related to status epilepticus due to left temporal multifocal hemorrhages. Brain computed tomography and angiogram showed left cortical vein congestion without intracranial arteriovenous shunt. Complementary left brachial angiogram showed a left BCV stenosis and jugular and cerebral high-flow venous reflux with cortical venous reflux from the hemodialysis fistula. The left arm shunt resulted in severe cerebral venous hypertension due to ipsilateral stenosis of the BCV. BCV angioplasty immediately resolved the cerebral reflux. Patients with hemodialysis fistulas are at a higher risk of developing these intracerebral hemorrhage complications.


Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Veias Braquiocefálicas , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/etiologia , Angiografia Digital , Angiografia Cerebral , Hemorragia Cerebral/terapia , Angiografia por Tomografia Computadorizada , Meios de Contraste , Escala de Coma de Glasgow , Humanos , Falência Renal Crônica/terapia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Diálise Renal
16.
J Stroke Cerebrovasc Dis ; 29(10): 105052, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912529

RESUMO

BACKROUND AND PURPOSE: Role of peri-procedural heparin as an adjuvant treatment during mechanical thrombectomy (MT) for patients contra-indicated for alteplase remains a source of debate. METHODS: We included patients from the multicenter French register ETIS that underwent MT without administration of alteplase, and compared patients who received heparin during MT with patients who did not. Heparin impact on outcome were analyzed regarding final TICI score, NIHSS at day one, modified rankin scale (mRS) and intracranial hemorrhagic transformation on imaging at day one. RESULTS: Over 1031 patients, 751 were included between January 2015 and June 2018 in 6 different centers, and 223 (26.69%) received heparin. Heparin administration was associated with a significant deleterious effect on NIHSS at 24h [adjusted OR = 1.2; p = 0.02], mRS at 3 months [adjusted OR 1.58; p = 0.03], and on complete reperfusion [TICI 3 adjusted OR 0.68; p = 0.02]. Heparin administration was associated with a significant reduction of hemorrhagic transformation [adjusted OR 0.48; p = 0.00005]. CONCLUSIONS: Heparin administration during MT seems deleterious for reperfusion and functional outcome. Randomized trials are needed to identify the role of antithrombotic treatments, such as heparin, in the setting of acute ischemic stroke management.


Assuntos
Anticoagulantes/efeitos adversos , Isquemia Encefálica/terapia , Contraindicações de Medicamentos , Fibrinolíticos/efeitos adversos , Heparina/administração & dosagem , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Isquemia Encefálica/diagnóstico , Feminino , França , Heparina/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Trombectomia/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
17.
J Neuroradiol ; 47(4): 278-283, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30853544

RESUMO

BACKGROUND AND PURPOSE: To compare the accuracy and utility of contrast enhanced magnetic resonance angiography (MRA) (CEMRA) to Time of Flight MRA (TOF MRA) during detection and evaluation of occlusions on patients diagnosed with acute ischemic stroke (AIS). METHODS: This single-center study was approved by our local institutional research ethics board. From August 2014 to July 2016, 131 consecutive adult patients with confirmed AIS were included. Detection of an arterial occlusion and its characterization were evaluated independently with CEMRA or TOF MRA by two blinded neuroradiologists, then by consensus using all available MR sequences. A Cohen's Kappa coefficient (κ) and intra-class correlation coefficients (ICC) were used to compare the two techniques. RESULTS: There was substantial concordance in the detection of arterial occlusion between CEMRA and TOF MRA (κ = 0.75). TOF MRA was more likely to show an arterial occlusion than CEMRA (63 versus 52 patients respectively). There were 13 and 1 false positive arterial occlusion with TOF MRA and CEMRA respectively, and 1 false negative with TOF MRA. There was excellent concordance between the location of arterial occlusions and CEMRA and TOF MRA [κ = 0.89 (0.72-0.97)]. CEMRA was significantly more likely to allow measurement of the thrombus than was TOF MRA [38 (75%) versus 14 (22%)] (P < 0.0001). CONCLUSIONS: Our study showed that CEMRA imaging detected arterial occlusions better than TOF MRA in AIS patients and more precisely such that thrombus length and location could be known, which improves the patient's management and care.


Assuntos
Artérias Cerebrais/diagnóstico por imagem , AVC Isquêmico/diagnóstico por imagem , Angiografia por Ressonância Magnética/métodos , Intensificação de Imagem Radiográfica , Artérias Cerebrais/patologia , Meios de Contraste , Humanos , AVC Isquêmico/patologia , Sensibilidade e Especificidade
18.
Stroke ; 50(9): 2364-2370, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31670928

RESUMO

Background and Purpose: Parenchymal hematoma (PH) is a rare but dreadful complication of acute ischemic stroke with unclear underlying mechanisms. We aimed to study the incidence and predictors of PH after mechanical thrombectomy. Methods: Data from a prospective observational multicenter registry was screened to identify acute ischemic stroke patients with an anterior circulation large vessel occlusion who underwent mechanical thrombectomy. Clinical, imaging, and procedural characteristics were used for the analysis, including brain imaging systematically performed at 24 hours. PH occurrence was assessed according to ECASS (European Collaborative Acute Stroke Study) criteria. Univariate and multivariable analyses were performed to identify predictors of PH. Results: A total of 1316 patients were included in the study. PH occurred in 153 out of 1316 patients (11.6%) and was associated with a lower rate of favorable outcome and increased mortality. On multivariable analysis, age (per 1 year increase, odds ratio [OR], 1.01; 95% CI, 1.00­1.03; P=0.05), current smoking (OR, 2.02; 95% CI, 1.32­3.09; P<0.01), admission Alberta Stroke Program Early CT Score (per a decrease of 1 point, OR, 1.70; 95% CI, 1.18­2.44; P<0.01), general anesthesia (OR, 1.98; 95% CI, 1.36­2.90; P<0.001), angiographic poor collaterals (OR, 2.13; 95% CI, 1.36­3.33; P<0.001) and embolization in new territory (OR, 2.94; 95% CI, 1.70­5.10; P<0.001) were identified as independent predictors of PH. Conclusions: PH occurred at a rate of 11.6% after mechanical thrombectomy, with high morbidity and mortality. Our study identified clinical, radiological, and procedural predictors of PH occurrence that can serve as the focus of future periprocedural management studies with the aim of reducing its occurrence.


Assuntos
Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/etiologia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Trombectomia/efeitos adversos , Idoso , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/tendências , Resultado do Tratamento
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