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  • 1
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    Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials
    Elsevier BV ; 2023
    In:  The Lancet Vol. 402, No. 10406 ( 2023-09), p. 965-974
    Details
    In: The Lancet, Elsevier BV, Vol. 402, No. 10406 ( 2023-09), p. 965-974
    Type of Medium: Online Resource
    ISSN: 0140-6736
    URL: Article
    DOI: 10.1016/S0140-6736(23)01142-X
    RVK:
    XA 10000
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2023
    detail.hit.zdb_id: 2067452-1
    detail.hit.zdb_id: 3306-6
    detail.hit.zdb_id: 1476593-7
    SSG: 5,21
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  • 2
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    Phenotypes of Chronic Covert Brain Infarction in Patients With First-Ever Ischemic Stroke: A Cohort Study
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. 2 ( 2022-02), p. 558-568
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. 2 ( 2022-02), p. 558-568
    Abstract: The aim of this study was to assess the rate of chronic covert brain infarctions (CBIs) in patients with acute ischemic stroke (AIS) and to describe their phenotypes and diagnostic value. Methods: This is a single-center cohort study including 1546 consecutive patients with first-ever AIS on magnetic resonance imaging imaging from January 2015 to December 2017. The main study outcomes were CBI phenotypes, their relative frequencies, location, and association with vascular risk factors. Results: Any CBI was present in 574/1546 (37% [95% CI, 35%–40%]) of patients with a total of 950 CBI lesions. The most frequent locations of CBI were cerebellar in 295/950 (31%), subcortical supratentorial in 292/950 (31%), and cortical in 213/950 (24%). CBI phenotypes included lacunes (49%), combined gray and white matter lesions (30%), gray matter lesions (13%), and large subcortical infarcts (7%). Vascular risk profile and white matter hyperintensities severity (19% if no white matter hyperintensity, 63% in severe white matter hyperintensity, P 〈 0.001) were associated with presence of any CBI. Atrial fibrillation was associated with cortical lesions (adjusted odds ratio, 2.032 [95% CI, 1.041–3.967]). Median National Institutes of Health Stroke Scale scores on admission were higher in patients with an embolic CBI phenotype (median National Institutes of Health Stroke Scale, 5 [2–10] , P =0.025). Conclusions: CBIs were present in more than a third of patients with first AIS. Their location and phenotypes as determined by MRI were different from previous studies using computed tomography imaging. Among patients suffering from AIS, those with additional CBI represent a vascular high-risk subgroup and the association of different phenotypes of CBIs with differing risk factor profiles potentially points toward discriminative AIS etiologies.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.121.034347
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 1467823-8
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  • 3
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    Abstract TMP3: Prediction Model For Medical Rescue Treatment Strategies In Patients With Incomplete Reperfusion
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke Vol. 54, No. Suppl_1 ( 2023-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 54, No. Suppl_1 ( 2023-02)
    Abstract: Background: After successful reperfusion is achieved (extended Thrombolysis in Cerebral Infarction (eTICI) ≥2b50), decision on pursuing additional treatment strategies in order to achieve complete reperfusion (eTICI=2c/3), is multifactorial and depends on patient’s clinical and imaging characteristics. We have developed and validated a clinical decision tool to provide individualized predictions on achieving delayed reperfusion based on individual patient data. Methods: Single-center registry analysis for all consecutive patients admitted between 02/2015 - 12/2020. Primary variable of interest was perfusion imaging outcome in patients with incomplete reperfusion (eTICI 2a-2c), evaluated on the 24-hour follow-up imaging. This variable was dichotomized into delayed reperfusion, in case of non-observable perfusion deficit, and persistent perfusion deficit, in case of perfusion deficit captured on the final angiography imaging. Final model variable selection was performed via bootstrapped (n=200) stepwise backwards regression. Model was split into a training and testing set (80:20 ratio), with 10-fold cross validation resampling. Results: 372 patients (50.8% female, mean age 74) were included, with 228 (61.2%) of them having delayed reperfusion. Final model identified seven variables of importance including: age, sex, atrial fibrillation, Intervention-to-Follow-Up time, maneuver count, eTICI and collateral status. Model’s discriminative ability for predicting delayed reperfusion was adequate (AUC 0.83, 95% CI 0.74 -0.92), with an overall adjusted calibration (Brier score 0.17, 95% CI 0.15-0.18). Conclusions: Current model presents a tool that may aid clinical decision-making process in selection of patients for pursuing additional treatment strategies after incomplete reperfusion has been achieved. This is an important next step towards personalized treatment of stroke patients undergoing mechanical thrombectomy.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.54.suppl_1.TMP3
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
    detail.hit.zdb_id: 1467823-8
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  • 4
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    Deep Learning Versus Neurologists: Functional Outcome Prediction in LVO Stroke Patients Undergoing Mechanical Thrombectomy
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke Vol. 54, No. 7 ( 2023-07), p. 1761-1769
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 54, No. 7 ( 2023-07), p. 1761-1769
    Abstract: Despite evolving treatments, functional recovery in patients with large vessel occlusion stroke remains variable and outcome prediction challenging. Can we improve estimation of functional outcome with interpretable deep learning models using clinical and magnetic resonance imaging data? METHODS: In this observational study, we collected data of 222 patients with middle cerebral artery M1 segment occlusion who received mechanical thrombectomy. In a 5-fold cross validation, we evaluated interpretable deep learning models for predicting functional outcome in terms of modified Rankin scale at 3 months using clinical variables, diffusion weighted imaging and perfusion weighted imaging, and a combination thereof. Based on 50 test patients, we compared model performances to those of 5 experienced stroke neurologists. Prediction performance for ordinal (modified Rankin scale score, 0–6) and binary (modified Rankin scale score, 0–2 versus 3–6) functional outcome was assessed using discrimination and calibration measures like area under the receiver operating characteristic curve and accuracy (percentage of correctly classified patients). RESULTS: In the cross validation, the model based on clinical variables and diffusion weighted imaging achieved the highest binary prediction performance (area under the receiver operating characteristic curve, 0.766 [0.727–0.803]). Performance of models using clinical variables or diffusion weighted imaging only was lower. Adding perfusion weighted imaging did not improve outcome prediction. On the test set of 50 patients, binary prediction performance between model (accuracy, 60% [55.4%–64.4%] ) and neurologists (accuracy, 60% [55.8%–64.21%]) was similar when using clinical data. However, models significantly outperformed neurologists when imaging data were provided, alone or in combination with clinical variables (accuracy, 72% [67.8%–76%] versus 64% [59.8%–68.4%] with clinical and imaging data). Prediction performance of neurologists with comparable experience varied strongly. CONCLUSIONS: We hypothesize that early prediction of functional outcome in large vessel occlusion stroke patients may be significantly improved if neurologists are supported by interpretable deep learning models.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.123.042496
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
    detail.hit.zdb_id: 1467823-8
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  • 5
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    Multivessel Occlusion in Patients Subjected to Thrombectomy : Prevalence, Associated Factors, and Clinical Implications
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. 6 ( 2018-06), p. 1355-1362
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. 6 ( 2018-06), p. 1355-1362
    Abstract: Patients with embolic large-vessel occlusion may present with additional coincidental acute occlusions within or distant from the involved territory, referred to as multivessel occlusion (MVO). Purpose of this study was to assess prevalence of MVO, associated factors, and clinical relevance in patients undergoing endovascular stroke treatment. Methods— Image data of consecutive endovascular candidates (n=720) with direct access to angiography were extracted from a prospective registry. Prevalence of MVO was assessed with multimodal magnetic resonance imaging/computed tomography and confirmed by intra-arterial angiography. Explorative analysis of associated factors and clinical relevance was evaluated using multivariable logistic regression including variables with P 〈 0.15 in univariate comparison. Good functional outcome was defined as modified Rankin Scale score ≤2 at day 90. Results— MVO was present in 10.7% of patients (95% confidence interval [CI], 6.4%–13.0%). Two, 3, and 4 concomitant occlusions were found in 80.5%, 16.9%, and 2.6% of MVO cases, respectively. Detection rate on initial radiological report was 54.5%. Downstream MVO was present in around one third of MVO (n=27/77, 35.1%), whereas all other MVO (n=50/77, 64.9%) occurred in different territories. Independent factors related to MVO were statin treatment (adjusted odds ratio [aOR] , 0.477; 95% CI, 0.276–0.827), higher systolic blood pressure (aOR per mm Hg increase, 1.014; 95% CI, 1.005–1.023), and primary occlusion site M2 (aOR, 1.870; 95% CI, 1.103–3.170). MVO was related to lower rates of successful reperfusion (aOR, 0.549; 95% CI, 0.316–0.953) and lower rates of good functional outcome (aOR, 0.437; 95% CI, 0.207–0.923). Conclusions— Every tenth patient subjected to angiography for endovascular stroke treatment experienced MVO in our series, and only half were prospectively identified on preinterventional diagnostic imaging. Patients with MVO had higher baseline systolic blood pressure and were less often medicated with statins, an observation that warrants external validation and evaluation regarding causality. Occurrence of MVO has implication for treatment decisions, negatively affects endovascular treatment success, and is predictive of worse clinical outcome.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.118.021276
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
    detail.hit.zdb_id: 1467823-8
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  • 6
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    Abstract 22: Time to Treatment and the Effect of Intravenous Thrombolysis Before Thrombectomy: An Individual Participant Data Meta-Analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2024
    In:  Stroke Vol. 55, No. Suppl_1 ( 2024-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 55, No. Suppl_1 ( 2024-02)
    Abstract: Introduction: The benefit of intravenous thrombolysis for acute ischemic stroke declines with longer time from symptom onset. It is not known whether a similar time-dependent treatment effect modification of intravenous thrombolysis (IVT) is present in patients undergoing thrombectomy. Methods: Individual participant data meta-analysis from six randomized controlled trials comparing IVT plus thrombectomy vs thrombectomy alone. Primary analysis was performed testing for heterogeneity of the treatment effect. We estimated the effect of onset-to-expected-IVT times on the association between allocated treatment (intravenous thrombolysis plus thrombectomy vs thrombectomy alone) and disability at 3 months (modified Rankin scale, mRS). Results: In 2313 participants (IVT plus thrombectomy [n = 1160]; thrombectomy alone [n = 1153] ; median age, 71 years, IQR 62-78 years; 44.3% female), the median onset-to-expected-IVT time was 2h 28min (IQR, 1h 46min to 3h 17min). We observed a statistically significant interaction between onset-to-expected-IVT times and treatment group effect (pinteraction=0.02), with the treatment effect of IVT plus thrombectomy vs thrombectomy alone declining over time (e.g., common adjusted Odds Ratio for a one-step mRS shift toward improvement 1.49, 95%CI 1.13-1.96 at 1h; 1.25, 95% CI 1.04-1.49 at 2h; 1.04, 95% CI 0.88-1.23 at 3h). If treated before 2h 20min after symptom onset, participants allocated to IVT plus thrombectomy were significantly less disabled at 90 days than participants allocated to thrombectomy alone. Conclusions: This individual participant data meta-analysis of patients with ischemic stroke presenting at thrombectomy-capable stroke centers demonstrated time-dependence of the treatment effect of IVT plus thrombectomy vs thrombectomy alone. Intravenous thrombolysis showed clinical benefit if it was administered within 2h 20min after symptom onset.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.55.suppl_1.22
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2024
    detail.hit.zdb_id: 1467823-8
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  • 7
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    Multivariable Prediction Model for Futile Recanalization Therapies in Patients With Acute Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Neurology Vol. 99, No. 10 ( 2022-09-6), p. e1009-e1018
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 99, No. 10 ( 2022-09-6), p. e1009-e1018
    Abstract: Very poor outcome despite IV thrombolysis (IVT) and mechanical thrombectomy (MT) occurs in approximately 1 of 4 patients with ischemic stroke and is associated with a high logistic and economic burden. We aimed to develop and validate a multivariable prognostic model to identify futile recanalization therapies (FRTs) in patients undergoing those therapies. Methods Patients from a prospectively collected observational registry of a single academic stroke center treated with MT and/or IVT were included. The data set was split into a training (N = 1,808, 80%) and internal validation (N = 453, 20%) cohort. We used gradient boosted decision tree machine learning models after k-nearest neighbor imputation of 32 variables available at admission to predict FRT defined as modified Rankin scale 5–6 at 3 months. We report feature importance, ability for discrimination, calibration, and decision curve analysis. Results A total of 2,261 patients with a median (interquartile range) age of 75 years (64–83 years), 46% female, median NIH Stroke Scale 9 (4–17), 34% IVT alone, 41% MT alone, and 25% bridging were included. Overall, 539 (24%) had FRT, more often in MT alone (34%) as compared with IVT alone (11%). Feature importance identified clinical variables (stroke severity, age, active cancer, prestroke disability), laboratory values (glucose, C-reactive protein, creatinine), imaging biomarkers (white matter hyperintensities), and onset-to-admission time as the most important predictors. The final model was discriminatory for predicting 3-month FRT (area under the curve 0.87, 95% CI 0.87–0.88) and had good calibration (Brier 0.12, 0.11–0.12). Overall performance was moderate (F1-score 0.63 ± 0.004), and decision curve analyses suggested higher mean net benefit at lower thresholds of treatment (up to 0.8). Conclusions This FRT prediction model can help inform shared decision making and identify the most relevant features in the emergency setting. Although it might be particularly useful in low resource healthcare settings, incorporation of further multifaceted variables is necessary to further increase the predictive performance.
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000200815
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 8
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    Systematic review and meta-analysis on outcome differences among patients with TICI2b versus TICI3 reperfusions: success revisited
    BMJ ; 2018
    In:  Journal of Neurology, Neurosurgery & Psychiatry Vol. 89, No. 9 ( 2018-09), p. 910-917
    Details
    In: Journal of Neurology, Neurosurgery & Psychiatry, BMJ, Vol. 89, No. 9 ( 2018-09), p. 910-917
    Abstract: A reperfusion quality of thrombolysis in cerebral infarction (TICI)≥2b has been set as the therapeutic angiography target for interventions in patients with acute ischaemic stroke. This study addresses whether the distinction between TICI2b and TICI3 reperfusions shows a clinically relevant difference on functional outcome. Methods A systematic literature review and meta-analysis was carried out and presented in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to test the primary hypothesis that TICI2b and TICI3 reperfusions are associated with different rates of modified Rankin Scale (mRS) ≤2 at day 90. Secondary endpoints included rates of haemorrhagic transformations, mortality and excellent functional outcome (mRS ≤1). Summary estimates of ORs (sOR) with 95% CI were calculated using the inverse variance heterogeneity model accounting for multiple true effect sizes. Results Fourteen studies on 2379 successfully reperfused patients were included (1131 TICI3, 1248 TICI2b). TICI3 reperfusions were associated with higher rates of functional independence (1.74, 95% CI 1.44 to 2.10) and excellent functional outcomes (2.01, 95% CI 1.60 to 2.53), also after including adjusted estimates. The safety profile of patients with TICI3 was superior, as demonstrated by lower rates of mortality (sOR 0.59, 95% CI 0.37 to 0.92) and symptomatic intracranial haemorrhages (sOR 0.42, 95% CI 0.25 to 0.71). Conclusion TICI3 reperfusions are associated with superior outcome and better safety profiles than TICI2b reperfusions. This effect seems to be independent of time and collaterals. As reperfusion quality is the most important modifiable predictor of patients’ outcome, a more conservative definition of successful therapy and further evaluation of treatment approaches geared towards achieving TICI3 reperfusions are desirable.
    Type of Medium: Online Resource
    ISSN: 0022-3050 , 1468-330X
    URL: Article
    URL: Article
    URL: Article
    DOI: 10.1136/jnnp-2017-317602
    DOI: 10.1136/jnnp-2017-317602.supp1
    DOI: 10.1136/jnnp-2017-317602.supp2
    RVK:
    XA 10000
    Language: English
    Publisher: BMJ
    Publication Date: 2018
    detail.hit.zdb_id: 1480429-3
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  • 9
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    Outcome of patients with large vessel occlusion in the anterior circulation and low NIHSS score
    Springer Science and Business Media LLC ; 2020
    In:  Journal of Neurology Vol. 267, No. 6 ( 2020-06), p. 1651-1662
    Details
    In: Journal of Neurology, Springer Science and Business Media LLC, Vol. 267, No. 6 ( 2020-06), p. 1651-1662
    Type of Medium: Online Resource
    ISSN: 0340-5354 , 1432-1459
    URL: Article
    DOI: 10.1007/s00415-020-09744-0
    RVK:
    XA 10000
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2020
    detail.hit.zdb_id: 1421299-7
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  • 10
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    Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. 11 ( 2018-11), p. 2643-2651
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. 11 ( 2018-11), p. 2643-2651
    Abstract: Sustained successful reperfusion is an important prognostic factor for good clinical outcome in acute ischemic stroke. We aimed to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies within a prospective cohort. Methods— A total of 711 stroke patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b/3) followed with magnetic resonance or computed tomographic angiography at 24 to 48 hours were included. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. Results are displayed as adjusted odds ratio (aOR) and 95% CI. Improvement in accuracy of additional imaging findings on angiography control runs after the intervention was evaluated by area under the curve. Results— Early reocclusion was observed in 16 of 711 successfully reperfused patients (2.3%; 95% CI, 1.1–3.3; median delay: 20 hours). Suggestive predictors were higher platelets on admission (aOR, 1.01; 95% CI, 1.01–1.02), prestroke functional dependence (aOR, 7.12; 95% CI, 1.49–34.03), and stroke of undetermined or other specified pathogenesis in the TOAST classification (aOR, 7.19; 95% CI, 1.10–47.05 and aOR, 36.50; 95% CI, 4.47–298.11, respectively). When implementing residual embolic fragments or stenosis at the thrombectomy site into the logistic regression model, discrimination between patients with and without reocclusion improved significantly (area under the curve, 0.955 versus 0.854; P =0.023). Early reocclusion was an independent predictor of unfavorable outcome at 90 days (aOR for modified Rankin Scale ≤2, 0.13; 95% CI, 0.03–0.57). Conclusions— Early reocclusion within 48 hours after successful mechanical thrombectomy is rare but associated with poor outcome. Patients with high platelets on admission and residual embolic fragments or stenosis at the thrombectomy site are at high risk for reocclusion, which may be prevented or corrected after carefully re-evaluating the last angiographic run.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.118.021685
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
    detail.hit.zdb_id: 1467823-8
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