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BACKGROUND: Whereas mechanical thrombectomy (MT) has become standard-of-care treatment for patients with salvageable brain tissue after acute stroke caused by large-vessel occlusions, the results of MT in patients with medium-vessel occlusions (MEVOs), particularly in the posterior cerebral artery (PCA), are not well known. METHODS: Using data from the international Stroke Thrombectomy and Aneurysm Registry (STAR), we assessed presenting characteristics and clinical outcomes for patients who underwent MT for primary occlusions in the P2 PCA segment. As a subanalysis, we compared the PCA MeVO outcomes with STAR's anterior circulation MeVO outcomes, namely middle cerebral artery (MCA) M2 and M3 segments. RESULTS: Of the 9812 patients in STAR, 43 underwent MT for isolated PCA MeVOs. The patients' median age was 69 years (interquartile range 61-79), and 48.8% were female. The median NIH Stroke Scale score was 9 (range 6-17). After recanalization, 67.4% of patients achieved successful recanalization (modified treatment in cerebral infarction score [mTICI] ≥ 2b), with a first-pass success rate of 44.2%, and 39.6% achieved a modified Rankin score of 0-2 at 90 days. Nine patients (20.9%) had died by the 90-day follow-up. In comparison with M2 and M3 MeVOs, there were no differences in presenting characteristics among the three groups. Patients with PCA MeVOs were less likely to undergo intra-arterial thrombolysis (4.7% PCA vs. 10.1% M2 vs. 16.2% M3, p = 0.046) or to achieve successful recanalization (mTICI ≥ 2b, 67.4%, 86.7%, 82.3%, respectively, p < 0.001); however, there were no differences in the rates of successful first-pass recanalization (44.2%, 49.8%, 52.3%, respectively, p = 0.65). CONCLUSIONS: We describe the STAR experience performing MT in patients with PCA MeVOs. Our analysis supports that successful first-pass recanalization can be achieved in PCA MEVOs at a rate similar to that in MCA MeVOs, although further study and possible innovation may be necessary to improve successful PCA MeVO recanalization rates.
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BACKGROUND: The outcomes of endovascular thrombectomy (EVT) for medium vessel occlusions (MeVOs) of specific vascular territories remain unknown. We aimed to investigate EVT outcomes by MeVO locations using the data from an ongoing international multicenter registry. METHODS: Patients with isolated MeVO who underwent EVT between January 2013 and December 2022 were retrospectively analyzed. Isolated MeVO was defined as an occlusion of the A2 or A3 (A2/A3), M2 or M3, and P2 or P3 (P2/P3). Outcomes included a 90-day modified Rankin score (mRS) of 0-2, successful recanalization (modified Thrombolysis in Cerebral Infarction score ≥ 2b), early neurological deterioration (END) or improvement (ENI), and 90-day mortality. END was defined as a worsening of ≥4 points from the baseline National Institutes of Health Stroke Scale (NIHSS) score within 24 h of EVT, while ENI was defined as an improvement of ≥4 points from the baseline NIHSS score within 24 h of EVT. RESULTS: 1744 MeVOs included. Compared to M2 occlusions (n = 1542, 88.4%), A2/A3 (n = 36, 2.1%) occlusions had lower odds of 90-day mRS 0-2 (adjusted odds ratio [aOR] 0.30, 95% confidence interval [CI] 0.11-0.80), and P2/P3 occlusions (n = 49, 2.8%) had lower odds of successful recanalization (aOR 0.19, 95% CI 0.07-0.50), and higher odds of END (aOR 3.53, 95% CI 1.35-9.25). Other outcomes showed no significant differences. CONCLUSIONS: A2/A3 occlusions were more likely to have worse outcomes compared to M2 occlusions after EVT for patients with isolated MeVOs.
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Procedimientos Endovasculares , Trombectomía , Humanos , Masculino , Femenino , Trombectomía/métodos , Anciano , Procedimientos Endovasculares/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Sistema de Registros , Anciano de 80 o más AñosRESUMEN
BACKGROUND: The definitive impact of onset to arterial puncture time (OPT) on 90-day mortality after endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) caused by anterior circulation large vessel occlusion (LVO) remains unknown. The present study aimed to evaluate the influence of OPT on 90-day mortality in anterior circulation AIS-LVO patients who underwent EVT. METHODS: Data from 33 international centers were retrospectively analyzed. The receiver operating characteristic curve analysis was used to identify a cutoff for OPT. A propensity score-matched analysis was performed. The primary outcome was 90-day mortality (modified Rankin Scale [mRS] 6). Secondary outcomes included mortality at discharge, 90-day good outcome (mRS 0-2), 90-day poor outcome (mRS 5-6), successful recanalization (defined as postprocedure modified Thrombolysis in Cerebral Infarction scale ≥2b), and intracranial hemorrhage. RESULTS: A total of 2842 AIS-LVO patients with EVT were included. The cutoff for OPT for 90-day mortality was 180 min. Of these 378 patients had OPT <180 min and 378 patients had OPT ≥180 min in the propensity score-matched cohort (n = 756). Patients with OPT <180 min were less likely to have 90-day mortality (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.51-0.96) and poor outcome (OR 0.71, 95% CI 0.53-0.96), and more likely to have 90-day good outcome (OR 1.55, 95% CI 1.16-2.08). Other outcomes showed no significant differences. CONCLUSIONS: This study showed that OPT <180 min was less related to 90-day mortality and poor outcome, and more to 90-day good outcome in AIS-LVO patients who underwent EVT.
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BACKGROUND AND OBJECTIVES: First pass effect (FPE) is a metric increasingly used to determine the success of mechanical thrombectomy (MT) procedures. However, few studies have investigated whether the duration of the procedure can modify the clinical benefit of FPE. We sought to determine whether FPE after MT for anterior circulation large vessel occlusion acute ischemic stroke is modified by procedural time (PT). METHODS: A multicenter, international data set was retrospectively analyzed for anterior circulation large vessel occlusion acute ischemic stroke treated by MT who achieved excellent reperfusion (thrombolysis in cerebral infarction 2c/3). The primary outcome was good functional outcome defined by 90-day modified Rankin scale scores of 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. We fit-adjusted logistic regression models and used marginal effects to assess the interaction between PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from stroke presentation. RESULTS: A total of 1310 patients had excellent reperfusion. These patients were divided into 2 cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and >30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant ( P = .018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs 46.7%, P = .001). However, there was no significant difference in the adjusted predicted probability of good outcome in individuals with PT >30 minutes. This relationship appeared identical in models with PT treated as a continuous variable. CONCLUSION: FPE is modified by PT, with the added clinical benefit lost in longer procedures greater than 30 minutes. A comprehensive metric for MT procedures, namely, FPE 30 , may better represent the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.
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BACKGROUND: Endovascular thrombectomy (EVT) remains the standard of care for acute large vessel occlusion (LVO) stroke. However, the safety and efficacy of repeat thrombectomy (rEVT) in recurrent LVO remains unclear. This study uses a large real-world patient cohort to study technical and clinical outcomes after rEVT. METHODS: This is a retrospective cohort study including patients who underwent thrombectomy between January 2013 and December 2022. Data were included from 21 comprehensive stroke centers globally through the Stroke Thrombectomy and Aneurysm Registry (STAR). Patients undergoing single EVT or rEVT within 30 days of LVO stroke were included in the study. Propensity score matching was used to compare patients undergoing single EVT versus rEVT. RESULTS: Out of a total of 7387 patients who underwent thrombectomy for LVO stroke, 90 (1.2%) patients underwent rEVT for the same vascular territory within 30 days. The median (IQR) time to re-occlusion was 2 (1-7) days. Compared with a matched cohort of patients undergoing a single EVT procedure, patients undergoing rEVT had a comparable rate of good functional outcome and mortality rate, but a higher rate of symptomatic intracranial hemorrhage (sICH). There was a significant reduction in the National Institutes of Health Stroke Scale (NIHSS) score of patients who underwent rEVT at discharge compared with baseline (-4.8±11.4; P=0.006). The rate of successful recanalization was similar in the single thrombectomy and rEVT groups (78% vs 80%, P=0.171) and between index and rEVT performed on the same patient (79% vs 80%; P=0.593). CONCLUSION: Short-interval rEVT is associated with an improvement in the NIHSS score following large vessel re-occlusion. Compared with single thrombectomy, there was a higher rate of sICH with rEVT, but without a significant impact on rates of functional independence or mortality.
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BACKGROUND: The influence of Alberta Stroke Program Early CT Score (ASPECTS) on outcomes following mechanical thrombectomy (MT) for acute ischemic stroke (AIS) patients with low ASPECTS remains unknown. In this study, we compared the outcomes of AIS patients treated with MT for large vessel occlusion (LVO) categorized by ASPECTS value. METHODS: We conducted a retrospective analysis involving 305 patients with AIS caused by LVO, defined as the occlusion of the internal carotid artery and/or the M1 segments of the middle cerebral artery, stratified into two groups: ASPECTS 2-3 and 4-5. The primary outcome was favorable outcome defined as a 90-day modified Rankin Scale (mRS) score of 0-3. Secondary outcomes were 90-day mRS 0-2, 90-day mortality, any intracerebral hemorrhage (ICH), and symptomatic ICH (sICH). We performed multivariable logistic regression analysis to evaluate the impact of ASPECTS 2-3 vs. 4-5 on outcomes. RESULTS: Fifty-nine patients (19.3%) had ASPECTS 2-3 and 246 (80.7%) had ASPECTS 4-5. Favorable outcomes showed no significant difference between the two groups (adjusted odds ratio [aOR]= 1.13, 95% confidence interval [CI]: 0.52-2.41, p=0.80). There were also no significant differences in 90-day mRS 0-2 (aOR= 1.65, 95% CI: 0.66-3.99, p=0.30), 90-day mortality (aOR= 1.14, 95% CI: 0.58-2.20, p=0.70), any ICH (aOR= 0.54, 95% CI: 0.28-1.00, p=0.06), and sICH (aOR= 0.70, 95% CI: 0.27-1.63, p = 0.40) between the groups. CONCLUSIONS: AIS patients with LVO undergoing MT with ASPECTS 2-3 had similar outcomes compared to ASPECTS 4-5.
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Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/terapia , Estudios Retrospectivos , Alberta , Trombectomía/efectos adversos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/terapia , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/terapia , Hemorragia Cerebral/etiología , Resultado del Tratamiento , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/terapiaRESUMEN
OBJECTIVE: To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT. METHODS: This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation. RESULTS: Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time. CONCLUSIONS: In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.
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BACKGROUND: Patient's age is an important factor in determining the risk of aneurysm rupture. However, there is limited data on how aneurysm morphology differs among age groups. We studied morphological characteristics of brain aneurysms among age groups in a large cohort. METHODS: Aneurysms from the Stroke Thrombectomy and Aneurysm Registry (STAR) were analyzed. The following parameters were included: location, size, neck, width, height, aspect ratio, and regular versus irregular morphology. The risk of rupture presentation was estimated using logistic regression. RESULTS: A total of 1407 unruptured and 607 ruptured saccular aneurysms were included. The most common locations of ruptured aneurysms in patients younger than 70 years-old were the middle cerebral artery (MCA) and the anterior communicating artery (ACOM). The most common location of ruptured aneurysms in patients older than 70 years-old were the posterior communicating artery (PCOM) and ACOM. The size of unruptured aneurysms increased with age (p < .001). Conversely, the size of ruptured aneurysms was similar among age groups (p = .142). Unruptured and ruptured aneurysms became more irregular at presentation with older age (p < .001 and p .025, respectively). Irregular morphology and location were associated with rupture status across all age groups in multivariate regression. CONCLUSIONS: Younger patients have small unruptured and ruptured aneurysms, and ruptured aneurysms are mostly located in the MCA and ACOM. Older patients have larger and more irregular unruptured aneurysms, and ruptured aneurysms are mostly located in the PCOM and ACOM. An irregular morphology increases the risk of rupture in all age groups.
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Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Femenino , Embarazo , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Trombectomía , Isquemia Encefálica/tratamiento farmacológico , Resultado del Tratamiento , Fibrinolíticos/uso terapéuticoRESUMEN
BACKGROUND: Reducing intracranial hemorrhage (ICH) can improve patient outcome in acute ischemic stroke (AIS) intervention. We sought to identify ICH risk factors after AIS thrombectomy. METHODS: This is a retrospective review of the Stroke Thrombectomy and Aneurysm Registry (STAR) database. All patients who underwent AIS thrombectomy with available ICH data were included. Multivariable regression models were developed to identify predictors of ICH after thrombectomy. Subgroup analyses were performed stratified by symptom status and European Cooperative Acute Stroke Study (ECASS) grade. RESULTS: The study cohort comprised 6860 patients. Any ICH and symptomatic ICH (sICH) occurred in 25% and 7% of patients, respectively. Hemorrhagic infarction 1 (HI1) occurred in 36%, HI2 in 24%, parenchymal hemorrhage 1 (PH1) in 22%, and PH2 in 17% of patients classified by ECASS grade. Intraprocedural complications independently predicted any ICH (OR 3.8083, P<0.0001), PH1 (OR 1.9053, P=0.0195), and PH2 (OR 2.7347, P=0.0004). Race also independently predicted any ICH (black: OR 0.5180, P=0.0017; Hispanic: OR 0.4615, P=0.0148), sICH (non-white: OR 0.4349, P=0.0107), PH1 (non-white: OR 3.1668, P<0.0001), and PH2 (non-white: OR 1.8689, P=0.0176), with white as the reference. Primary mechanical thrombectomy technique also independently predicted ICH. ADAPT (A Direct Aspiration First Pass Technique) was a negative predictor of sICH (OR 0.2501, P<0.0001), with stent retriever as the reference. CONCLUSIONS: This study identified ICH risk factors after AIS thrombectomy using real-world data. There was a propensity towards a reduced sICH risk with direct aspiration. Procedural complications and ethnicity were predictors congruent between categories of any ICH, sICH, PH1, and PH2. Further investigation of technique and ethnicity effects on ICH and outcomes after AIS thrombectomy is warranted.
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Aneurisma , Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Accidente Cerebrovascular Isquémico/etiología , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/cirugía , Isquemia Encefálica/complicaciones , Resultado del Tratamiento , Accidente Cerebrovascular/diagnóstico , Hemorragias Intracraneales/etiología , Trombectomía/efectos adversos , Trombectomía/métodos , Factores de Riesgo , Estudios Retrospectivos , Aneurisma/complicaciones , Sistema de RegistrosRESUMEN
BACKGROUND: Recent clinical trials have shown that mechanical thrombectomy is superior to medical management for large vessel occlusion for up to 24 hours from onset. Our objective is to examine the safety and efficacy of thrombectomy beyond the standard of care window. METHODS: A retrospective review was undertaken of the multicenter Stroke Thrombectomy and Aneurysm Registry (STAR). We identified patients who underwent mechanical thrombectomy for large vessel occlusion beyond 24 hours. We selected a matched control group from patients who underwent thrombectomy in the 6-24-hour window. We used functional independence at 3 months as our primary outcome measure. RESULTS: We identified 121 patients who underwent thrombectomy beyond 24 hours and 1824 in the 6-24-hour window. We selected a 2:1 matched group of patients with thrombectomy 6-24 hours as a comparison group. Patients undergoing thrombectomy beyond 24 hours were less likely to be independent at 90 days (18 (18.8%) vs 73 (34.9%), P=0.005). They had higher odds of mortality at 90 days in the adjusted analysis (OR 2.34, P=0.023). Symptomatic intracerebral hemorrhage and other complications were similar in the two groups. In a multivariate analysis only lower number of attempts was associated with good outcomes (OR 0.27, P=0.022). CONCLUSIONS: Mechanical thrombectomy beyond 24 hours appears to be safe and tolerable with no more hemorrhages or complications compared with standard of care thrombectomy. Outcomes and mortality in this time window are worse compared with an earlier time window, but the rates of good outcomes may justify this therapy in selected patients.
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Isquemia Encefálica , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/cirugía , Isquemia Encefálica/complicaciones , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/cirugía , Accidente Cerebrovascular/etiología , Trombectomía/efectos adversos , Hemorragia Cerebral/etiología , Procedimientos Endovasculares/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Endovascular thrombectomy (EVT) has become the mainstay treatment for large vessel occlusion, with favorable safety and efficacy profile. However, the safety and efficacy of EVT in concurrent multi-territory occlusions (MTVOs) remains unclear. OBJECTIVE: To investigate the prevalence, clinical and technical outcomes of concurrent EVT for MTVOs. METHODS: Data were included from the Stroke Thrombectomy and Aneurysm Registry (STAR) with 32 stroke centers for EVT performed to treat bilateral anterior or concurrent anterior and posterior circulation occlusions between 2017 and 2021. Patients with MTVO were identified, and propensity score matching was used to compare this group with patients with occlusion in a single arterial territory. RESULTS: Of a total of 7723 patients who underwent EVT for acute ischemic stroke, 54 (0.7%) underwent EVT for MTVOs (mean age 69±12.5; female 50%). 28% had bilateral and 72% had anterior and posterior circulations occlusions. The rate of successful recanalization (Thrombolysis in Cerebral Infarction 2b/3), complications, modified Rankin score at 90 days, and mortality was not significantly different between the matched cohorts. Multivariate analysis confirmed that MTVOs were not associated with poor functional outcome, symptomatic intracranial hemorrhage, or longer procedure time. CONCLUSION: Compared with EVT for single vessel occlusions, EVT in appropriately selected patients with MTVOs has a similar efficacy and safety profile.
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OBJECTIVE: The role of endovascular mechanical thrombectomy (MT) in patients presenting with "minor" stroke is uncertain. We aimed to compare outcomes after MT for ischemic stroke patients presenting with National Institutes of Health Stroke Scale (NIHSS) 5 and - within the low NIHSS cohort - identify predictors of a favorable outcome, mortality, and symptomatic intracranial hemorrhage (ICH). METHODS: We retrospectively analyzed a prospectively maintained, international, multicenter database. RESULTS: The study cohort comprised a total of 7568 patients from 29 centers. NIHSS was low (<5) in 604 patients (8%), and > 5 in 6964 (92%). Patients with low NIHSS were younger (67 + 14.8 versus 69.6 + 14.7 years, p < 0.001), more likely to have diabetes (31.5% versus 26.9%, p = 0.016), and less likely to have atrial fibrillation (26.6% versus 37.6%, p < 0.001) compared to those with higher NIHSS. Radiographic outcomes (TICI > 2B 84.6% and 84.3%, p = 0.412) and complication rates (8.1% and 7.2%, p = 0.463) were similar between the low and high NIHSS groups, respectively. Clinical outcomes at every follow up interval, including NIHSS at 24 h and discharge, and mRS at discharge and 90 days, were better in the low NIHSS group, however patients in the low NIHSS group experienced a relative decline in NIHSS from admit to discharge. Mortality was lower in the low NIHSS group (10.4% versus 24.5%, p < 0.001). CONCLUSIONS: Relative to patients with high NIHSS, MT is safe and effective for stroke patients with low NIHSS, and it is reasonable to offer it to appropriately selected patients presenting with minor stroke symptoms. Our findings justify efforts towards a randomized trial comparing MT versus medical management for patients with low NIHSS.
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Isquemia Encefálica , Procedimientos Endovasculares , Accidente Cerebrovascular , Estados Unidos , Humanos , Estudios Retrospectivos , Trombectomía/efectos adversos , Resultado del Tratamiento , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/cirugía , National Institutes of Health (U.S.) , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/cirugía , Procedimientos Endovasculares/efectos adversosRESUMEN
The cerebral arteries are innervated by afferent fibers from the trigeminal ganglia. Varicella-zoster virus (VZV) frequently resides in the trigeminal ganglion. Reports of arterial ischemic stroke due to VZV cerebral vasculopathy in adults after herpes zoster have been described for decades. Reports of arterial ischemic stroke due to post-varicella cerebral arteriopathy in children have also been described for decades. One rationale for this review has been post-licensure studies that have shown an apparent protective effect from stroke in both adults who have received live zoster vaccine and children who have received live varicella vaccine. In this review, we define common features between stroke following varicella in children and stroke following herpes zoster in adults. The trigeminal ganglion and to a lesser extent the superior cervical ganglion are central to the stroke pathogenesis pathway because afferent fibers from these two ganglia provide the circuitry by which the virus can travel to the anterior and posterior circulations of the brain. Based on studies in pseudorabies virus (PRV) models, it is likely that VZV is carried to the cerebral arteries on a kinesin motor via gE, gI and the homolog of PRV US9. The gE product is an essential VZV protein.
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Varicela , Herpes Zóster , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Adulto , Niño , Humanos , Herpesvirus Humano 3 , Varicela/prevención & control , Ganglio del Trigémino/patología , Accidente Cerebrovascular/patologíaRESUMEN
BACKGROUND: Current imaging modalities underestimate the severity of intracranial atherosclerotic disease (ICAD). High resolution vessel wall imaging (HR-VWI) MRI is a powerful tool in characterizing plaques. We aim to show that HR-VWI MRI is more accurate at detecting and characterizing intracranial plaques compared to digital subtraction angiography (DSA), time-of-flight (TOF) MRA, and computed tomography angiogram (CTA). METHODS: Patients with symptomatic ICAD prospectively underwent 7T HR-VWI. We calculated: degree of stenosis, plaque burden (PB), and remodeling index (RI). The sensitivity of detecting a culprit plaque for each modality as well as the correlations between different variables were analyzed. Interobserver agreement on the determination of a culprit plaque on every imaging modality was evaluated. RESULTS: A total of 44 patients underwent HR-VWI. Thirty-four patients had CTA, 18 TOF-MRA, and 18 DSA. The sensitivity of plaque detection was 88% for DSA, 78% for TOF-MRA, and 76% for CTA. There's significant positive correlation between PB and degree of stenosis on HR-VWI MRI (p < 0.001), but not between PB and degree of stenosis in DSA (p = 0.168), TOF-MRA (p = 0.144), and CTA (p = 0.253). RI had a significant negative correlation with degree of stenosis on HR-VWI MRI (p = 0.003), but not on DSA (p = 0.783), TOF-MRA (p = 0.405), or CTA (p = 0.751). The best inter-rater agreement for culprit plaque detection was with HR-VWI (p = 0.001). CONCLUSIONS: The degree of stenosis measured by intra-luminal techniques does not fully reflect the true extent of ICAD. HR-VWI is a more accurate tool in characterizing atherosclerotic plaques and may be the default imaging modality in clinical practice.
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Importance: There is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy. Objective: To assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI). Design, Setting, and Participants: In this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022. Exposures: Selection by NCCT, CTP, or DWI. Main Outcomes and Measures: Primary outcome was functional independence (modified Rankin scale 0-2) at 90 days. Results: Among 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups. Conclusions and Relevance: In this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.
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Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Estudios de Cohortes , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/cirugía , Perfusión , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the influence of solid organ malignancies on the in-hospital outcomes and recurrent strokes among patients hospitalized with acute ischemic stroke (AIS). METHODS: Adult hospitalizations with a primary diagnosis of AIS were identified from the Nationwide Readmissions Database 2016-2018. Logistic regression was used to compare the differences in the utilization of acute stroke interventions and clinical outcomes in patients with and without malignancy. Survival analysis was used to evaluate the risk of readmission due to recurrent stroke after discharge. RESULTS: There were 1385840 hospitalizations due to AIS (mean±SD age 70.4±14.0 years, female 50.2%). Of these, 50553 (3.7%) had a concurrent diagnosis of solid organ malignancy. The five most common malignancies included lung cancer (24.6%), prostate cancer (13.2%), breast cancer (9.3%), pancreatic cancer (6.5%), and colorectal cancer (6.2%). After adjustment for baseline differences, patients with malignancy were more likely to have intraparenchymal hemorrhage (IPH) [odds ratio (OR): 1.11, 95% confidence interval (CI): 1.04-1.19], in-hospital mortality (OR: 2.15, 95% CI: 2.04-2.28), and discharge disposition other than to home (OR: 1.70, 95% CI: 1.64-1.75). Patients with malignancy were less likely to receive intravenous thrombolysis (tPA) and were more likely to undergo mechanical thrombectomy (MT). Among the subgroups of patients treated with tPA or MT, the outcomes were comparable between patients with and without malignancy, except patients with lung cancer remained at a higher risk of mortality and adverse disposition despite these acute stroke interventions. Patients with malignancy were at a higher risk of readmission due to recurrent AIS within 1 year of discharge (hazards ratio: 1.18, 95% CI: 1.11-1.25), and this risk was specifically driven by the lung and pancreatic cancers. CONCLUSION: While patients with malignancy generally have worse in-hospital outcomes as compared to those without, there is considerable variation in these outcomes according to the different cancer types and the use of acute stroke interventions. The use of tPA and MT is generally safe for eligible patients with an underlying malignancy. Patients with lung and pancreatic cancers have a higher early risk of recurrent stroke and might need more intensive surveillance and careful institution of the optimal secondary prevention measures.
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BACKGROUND: The mechanism of increased risk of venous thromboembolism (VTE) after acute ischemic stroke (AIS) is unclear. In this study, we aimed to evaluate the risk of VTE in hospitalizations due to AIS as compared to those due to non-vascular neurological conditions. We also aimed to assess any potential association between VTE risk and the use of intravenous thrombolysis (rtPA) among hospitalizations with AIS. MATERIALS AND METHODS: In this case-control study, data were obtained from the Nationwide Inpatient Sample 2016-2018. Propensity score matching was used to adjust for the baseline differences between the groups. Logistic regression analysis was used to compare the risk of VTE. RESULTS: We identified 1,541,685 hospitalizations due to AIS and 1,453,520 hospitalizations due to non-vascular neurological diagnoses that served as controls. After propensity score matching, 640,560 cases with AIS and corresponding well-matched controls were obtained. Hospitalizations due to AIS had higher odds of VTE as compared to the controls [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.40-1.60, P<0.001]. Among hospitalizations with AIS, 184,065 (11.9%) got rtPA. The odds of VTE were lower among the AIS hospitalizations that received rtPA as compared to those that did not (OR 0.89, 95% CI 0.79-0.99, P0.035). CONCLUSION: Hospitalizations due to AIS have a higher risk of VTE as compared to the non-vascular neurological controls. Among AIS cases, the risk of VTE is lower among patients treated with rtPA. These epidemiological findings support the hypothesis that the risk of VTE after AIS might be partly mediated by an intrinsic pro-coagulant state.
Asunto(s)
Accidente Cerebrovascular Isquémico , Enfermedades del Sistema Nervioso , Tromboembolia Venosa , Estudios de Casos y Controles , Hospitalización , Humanos , Accidente Cerebrovascular Isquémico/epidemiología , Accidente Cerebrovascular Isquémico/terapia , Enfermedades del Sistema Nervioso/epidemiología , Enfermedades del Sistema Nervioso/terapia , Medición de Riesgo , Tromboembolia Venosa/epidemiologíaRESUMEN
OBJECTIVE: To determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates. METHODS: We retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality. RESULTS: We identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality. CONCLUSIONS: The ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.