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  • Ovid Technologies (Wolters Kluwer Health)  (9)
  • Guillemin, Francis  (9)
  • 1
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    Abstract 174: Public Health Potential of Improved Reperfusion in Thrombectomy for Stroke Based on HERMES Collaboration Data
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Introduction: The benefit that endovascular thrombectomy (EVT) offers to stroke patients with large vessel occlusions depends strongly on reperfusion grade as defined by the mTICI (modified Thrombolysis in Cerebral Infarction) scale. Our aim was to estimate the public health potential of improved reperfusion. Methods: A Markov model estimated lifetime quality-adjusted life years (QALY) of EVT-treated patients and associated costs based on mTICI grades. The analysis was performed from a United States healthcare perspective. Input parameters were based on best available evidence, including patient data from the HERMES collaboration. The lead analysis was conducted for stroke onset at 65 years. Overall lifetime costs and the net monetary benefit (NMB), which combines weighted QALYs and costs into one composite outcome, were analyzed. A willingness-to-pay threshold of $100,000 per QALY was used for NMB calculations. Results: Lifetime QALYs and the NMB per patient increased for every grade of improved mTICI reperfusion (Fig 1). The final mTICI 2C/3 rate across all trials in the HERMES collaboration was 31%, yielding on average 5.09 QALYs at lifetime costs of $230,799, resulting in a positive NMB of $278,336. Every 10% increase in the final mTICI 2C/3 rate would yield 0.16 incremental QALYs and $16,878 incremental NMB for the average patient. For a national 10% improvement of the mTICI 2C/3 rate of all EVT-treated patients in the United States, we estimated 3,645 additional QALYs and an incremental NMB of $385 million per year. Conclusions: The public health and economic impact of the grade of reperfusion is significant, warranting further improvement of devices and procedural techniques.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.174
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 1467823-8
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  • 2
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    Prediction of Outcome and Endovascular Treatment Benefit: Validation and Update of the MR PREDICTS Decision Tool
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke Vol. 52, No. 9 ( 2021-09), p. 2764-2772
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 52, No. 9 ( 2021-09), p. 2764-2772
    Abstract: Benefit of early endovascular treatment (EVT) for ischemic stroke varies considerably among patients. The MR PREDICTS decision tool, derived from MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), predicts outcome and treatment benefit based on baseline characteristics. Our aim was to externally validate and update MR PREDICTS with data from international trials and daily clinical practice. Methods: We used individual patient data from 6 randomized controlled trials within the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration to validate the original model. Then, we updated the model and performed a second validation with data from the observational MR CLEAN Registry. Primary outcome was functional independence (defined as modified Rankin Scale score 0–2) 3 months after stroke. Treatment benefit was defined as the difference between the probability of functional independence with and without EVT. Discriminative performance was evaluated using a concordance (C ) statistic. Results: We included 1242 patients from HERMES (633 assigned to EVT, 609 assigned to control) and 3156 patients from the MR CLEAN Registry (all of whom underwent EVT within 6.5 hours). The C -statistic for functional independence was 0.74 (95% CI, 0.72–0.77) in HERMES and, after model updating, 0.80 (0.78–0.82) in the Registry. Median predicted treatment benefit of routinely treated patients (Registry) was 10.3% (interquartile range, 5.8%–14.4%). Patients with low ( 〈 1%) predicted treatment benefit (n=135/3156 [4.3%]) had low rates of functional independence, irrespective of reperfusion status, suggesting potential absence of treatment benefit. The updated model was made available online for clinicians and researchers at www.mrpredicts.com . Conclusions: Because of the substantial treatment effect and small potential harm of EVT, most patients arriving within 6 hours at an endovascular-capable center should be treated regardless of their clinical characteristics. MR PREDICTS can be used to support clinical judgement when there is uncertainty about the treatment indication, when resources are limited, or before a patient is to be transferred to an endovascular-capable center.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.120.032935
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 3
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    Correlation Between Computed Tomography-Based Tissue Net Water Uptake and Volumetric Measures of Cerebral Edema After Reperfusion Therapy
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. 8 ( 2022-08), p. 2628-2636
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. 8 ( 2022-08), p. 2628-2636
    Abstract: Cerebral edema after large hemispheric infarction is associated with poor functional outcome and mortality. Net water uptake (NWU) quantifies the degree of hypoattenuation on unenhanced-computed tomography (CT) and is increasingly used to measure cerebral edema in stroke research. Hemorrhagic transformation and parenchymal contrast staining after thrombectomy may confound NWU measurements. We investigated the correlation of NWU measured postthrombectomy with volumetric markers of cerebral edema and association with functional outcomes. Methods: In a pooled individual patient level analysis of patients presenting with anterior circulation large hemispheric infarction (core 80–300 mL or Alberta Stroke Program Early CT Score ≤5) in the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set, cerebral edema was defined as the volumetric expansion of the ischemic hemisphere expressed as a ratio to the contralateral hemisphere(rHV). NWU and midline-shift were compared with rHV as the reference standard on 24-hour follow-up CT, adjusted for hemorrhagic transformation and the use of thrombectomy. Association between edema markers and day 90 functional outcomes (modified Rankin Scale) was assessed using ordinal logistic regression. Results: Overall (n=144), there was no correlation between NWU and rHV (r s =0.055, P =0.51). In sub-group analyses, a weak correlation between NWU with rHV was observed after excluding patients with any degree of hemorrhagic transformation (r s =0.211, P =0.015), which further improved after excluding thrombectomy patients (r s =0.453, P =0.001). Midline-shift correlated strongly with rHV in all sub-group analyses (r s 〉 0.753, P =0.001). Functional outcome at 90 days was negatively associated with rHV (adjusted common odds ratio, 0.46 [95% CI, 0.32–0.65]; P 〈 0.001) and midline-shift (adjusted common odds ratio, 0.85 [95% CI, 0.78–0.92]; P 〈 0.001) but not NWU (adjusted common odds ratio, 1.00 [95% CI, 0.97–1.03]; P =0.84), adjusted for age, baseline National Institutes of Health Stroke Scale, and thrombectomy. Prognostic performance of NWU improved after excluding patients with hemorrhagic transformation and thrombectomy (adjusted odds ratio, 0.90 [95% CI, 0.80–1.02]; P =0.10). Conclusions: NWU correlated poorly with conventional markers of cerebral edema and was not associated with clinical outcome in the presence of hemorrhagic transformation and thrombectomy. Measuring NWU postthrombectomy requires validation before implementation into clinical research. At present, the use of NWU should be limited to baseline CT, or follow-up CT only in patients without hemorrhagic transformation or treatment with thrombectomy.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.121.037073
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 4
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    Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window: A Pooled Analysis of Patient-Level Data
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. 4 ( 2022-04), p. 1348-1353
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. 4 ( 2022-04), p. 1348-1353
    Abstract: The optimal imaging paradigm for endovascular thrombectomy (EVT) patient selection in early time window (0–6 hours) treated acute ischemic stroke patients remains uncertain. We aimed to compare post-EVT outcomes between patients who underwent prerandomization basic (noncontrast computed tomography [CT], CT angiography only) versus additional advanced imaging (computed tomography perfusion [CTP] imaging) and to determine the association of performance of prerandomization CTP imaging with clinical outcomes. Methods: The HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) pooled patient-level data from randomized controlled trials comparing EVT with usual care for acute ischemic stroke due to anterior circulation large vessel occlusion. Good functional outcome, defined as modified Rankin Scale score 0 to 2 at 90 days, was compared between randomized patients with and without CTP baseline imaging. Univariable and multivariable binary logistic regression analysis was performed to determine the association of baseline CTP imaging and good functional outcome. Results: We analyzed 1348 patients 610 (45.3%) of whom underwent CTP prerandomization. The benefit of EVT compared with best medical management was maintained irrespective of the baseline imaging paradigm (90-day modified Rankin Scale score 0–2 in EVT versus control patients: with CTP: 46.0% (137/298) versus 28.9% (88/305), without CTP: 44.1% (162/367) versus 27.3% (100/366). Performance of CTP baseline imaging compared with baseline noncontrast CT and CT angiography only yielded similar rates of good outcome (odds ratio, 1.05 [95% CI, 0.82–1.33], adjusted odds ratio, 1.04, [95% CI, 0.80–1.35] ). Conclusions: Rates of good functional outcome were similar among patients in whom CTP was or was not performed, and EVT treatment effect in the 0- to 6-hour time window was similar in patients with and without baseline CTP imaging.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.121.034331
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 5
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    Abstract WMP7: Poor Reperfusion After Endovascular Therapy is Associated With Worse Outcomes Than No Intervention in the HERMES Analysis of Seven Randomized Trials
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Introduction: Although the role of successful reperfusion in improved outcome after endovascular treatment (EVT) for stroke is known, there has been limited evaluation of the effects of poor reperfusion. We compared results in the HERMES collaboration between standard care and those in the EVT group with poor reperfusion. Methods: Patient-level data were pooled in this meta-analysis of seven randomized trials comparing endovascular thrombectomy with standard care in anterior ischemic stroke. Functional outcome was assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days, comparing standard care versus EVT subjects achieving mTICI of 0 or 1 post-procedure. Analyses were adjusted for baseline prognostic variables to correct for potential imbalances. Results: The meta-analysis included 877 subjects in the standard care group and 78 in the EVT group with mTICI 0-1 per the HERMES central imaging core laboratory. At baseline, the EVT cohort had higher NIHSS (median 19 vs 17, p=0.011), but was not significantly different from standard care in other characteristics including age, sex, ASPECTS, time to randomization, site of occlusion and alteplase administration. Subjects with poor reperfusion in the EVT group had worse mRS at 90 days than standard care, unadjusted (p=0.003) and after adjustment for baseline characteristics (common odds ratio 0.59 (0.38-0.91), p=0.016). Fewer subjects in the EVT poor-reperfusion cohort achieved mRS 0, mRS 0-1 and all other dichotomized mRS cutpoints (Figure 1). Symptomatic intracranial hemorrhage was not different between groups (3.9% vs 3.5%, p=0.75). Conclusion: In recent endovascular trials, poor reperfusion after EVT was associated with worse outcomes than standard care in recent endovascular trials. This suggests that additional efforts to achieve reperfusion by EVT should be encouraged if deemed safe to do so.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.WMP7
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 6
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    Abstract 75: Hemorrhagic Transformation After Acute Ischemic Stroke Due to a Large Vessel Occlusion is Associated With Less Treatment Benefit
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: Introduction: Intracranial hemorrhage after acute ischemic stroke patients manifests as natural progression or as a complication of treatment with potential subsequent neurological deterioration. Currently it is unclear whether these hemorrhagic transformations (HT) contribute to the poorer functional outcomes observed in patients with large infarcts. The purpose of this study is to assess the association of HT with follow-up infarct volume (FIV) and functional outcome at 90 days after AIS. Additionally, we determined whether the development of HT was associated with a diminished endovascular therapy (EVT) effect. Methods: All patients from the HERMES collaboration with follow-up imaging were included. HERMES is pooled data from seven randomized controlled trials that assessed the efficacy and safety of EVT compared to usual care. Patients with HT were identified according to the ECASS classification and FIV was assessed on CT or MRI. Infarct and hemorrhage were included in the FIV. We assessed functional outcome using the modified Rankin Scale 90 days after stroke onset. Ordinal logistic regression with adjustment for potential confounders was used to determine the association of HT and FIV with functional outcome. Results: Of all included patients with follow-up imaging (n=1665), 42% had HT (n=698). Before and after adjustment for confounders HT and FIV were associated with a shift in the direction of poorer functional outcome (aOR:0.71,95%CI:0.58-0.86 and aOR:0.99,95%CI:0.99-0.99). EVT was beneficial in patients with and without HT, but effect was greater in patients without (aOR:1.70,95%CI:1.27-2.28 vs. aOR:2.51,95%CI:1.97-3.20)(figure 1.) Conclusions: In this analysis, patients with HT after AIS were less likely to have good functional outcome compared to those without HT, independent of the FIV. While the EVT effect was slightly diminished in patients who developed HT, EVT was always of significant benefit.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.75
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 7
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    Cerebral Edema in Patients With Large Hemispheric Infarct Undergoing Reperfusion Treatment: A HERMES Meta-Analysis
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke Vol. 52, No. 11 ( 2021-11), p. 3450-3458
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 52, No. 11 ( 2021-11), p. 3450-3458
    Abstract: Whether reperfusion into infarcted tissue exacerbates cerebral edema has treatment implications in patients presenting with extensive irreversible injury. We investigated the effects of endovascular thrombectomy and reperfusion on cerebral edema in patients presenting with radiological evidence of large hemispheric infarction at baseline. Methods: In a systematic review and individual patient-level meta-analysis of 7 randomized controlled trials comparing thrombectomy versus medical therapy in anterior circulation ischemic stroke published between January 1, 2010, and May 31, 2017 (Highly Effective Reperfusion Using Multiple Endovascular Devices collaboration), we analyzed the association between thrombectomy and reperfusion with maximal midline shift (MLS) on follow-up imaging as a measure of the space-occupying effect of cerebral edema in patients with large hemispheric infarction on pretreatment imaging, defined as diffusion-magnetic resonance imaging or computed tomography (CT)-perfusion ischemic core 80 to 300 mL or noncontrast CT-Alberta Stroke Program Early CT Score ≤5. Risk of bias was assessed using the Cochrane tool. Results: Among 1764 patients, 177 presented with large hemispheric infarction. Thrombectomy and reperfusion were associated with functional improvement (thrombectomy common odds ratio =2.30 [95% CI, 1.32–4.00]; reperfusion common odds ratio =4.73 [95% CI, 1.66–13.52] ) but not MLS (thrombectomy β=−0.27 [95% CI, −1.52 to 0.98]; reperfusion β=−0.78 [95% CI, −3.07 to 1.50] ) when adjusting for age, National Institutes of Health Stroke Score, glucose, and time-to-follow-up imaging. In an exploratory analysis of patients presenting with core volume 〉 130 mL or CT-Alberta Stroke Program Early CT Score ≤3 (n=76), thrombectomy was associated with greater MLS after adjusting for age and National Institutes of Health Stroke Score (β=2.76 [95% CI, 0.33–5.20]) but not functional improvement (odds ratio, 1.71 [95% CI, 0.24–12.08] ). Conclusions: In patients presenting with large hemispheric infarction, thrombectomy and reperfusion were not associated with MLS, except in the subgroup with very large core volume ( 〉 130 mL) in whom thrombectomy was associated with increased MLS due to space-occupying ischemic edema. Mitigating cerebral edema-mediated secondary injury in patients with very large infarcts may further improve outcomes after reperfusion therapies.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.120.033246
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 8
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    Effect of Endovascular Treatment in HERMES Patients With Isolated Occlusion of the Intracranial Internal Carotid Artery
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke: Vascular and Interventional Neurology
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health)
    Abstract: The optimal management of patients with symptomatic isolated internal carotid artery (ICA) occlusion is unknown. We aimed to assess whether endovascular treatment (EVT) compared with standard medical care was associated with improved functional outcomes in patients with acute symptomatic isolated intracranial ICA occlusion without involvement of the middle or anterior cerebral artery, that is, ICA‐I occlusion. Additionally, we aimed to compare ICA‐I with ICA‐L/T occlusion, which involves themiddle and anterior cerebral artery, respectively. METHODS We analyzed data from the highly effective reperfusion evaluated in multiple endovascular stroke trials (HERMES) collaboration, which performed an individual patient data meta‐analysis of 7 randomized controlled trials conducted between 2010 and 2017 assessing the benefit of EVT compared to medical management in patients with anterior circulation large vessel occlusion. We assessed the association between EVT and 90‐day good functional outcome (modified Rankin scale scores 0–2), National Institutes of Health Stroke Scale scores at 24 hours, symptomatic intracranial hemorrhage rates and mortality in patients with ICA‐I and ICA‐L/T occlusion. RESULTS We included 442 patients with intracranial ICA occlusion, of whom 38 (8.6%) had ICA‐I occlusion. In the ICA‐I group, the median age [interquartile range] was 69.5 [61.7–79.5] years, 42.1% were male, and median baseline National Institutes of Health Stroke Scale was 17 [15–20]. Compared with standard medical care alone, EVT resulted in higher good outcome rates in patients with ICA‐I (42.9% versus 25%; P =0.296) and ICA‐L/T occlusion (32.5% versus 14.4%; P 〈 0.001), and significant improvement in National Institutes of Health Stroke Scale scores at 24 hours. Mortality and symptomatic intracranial hemorrhage rates were similar between the treatment groups for both occlusion types. CONCLUSIONS A minority of patients with intracranial carotid occlusion presented with ICA‐I occlusion in the HERMES population. EVT in patients with ICA‐I occlusion and moderate‐to‐severe deficit was safe and tended to be similarly effective as compared to patients with ICA‐L/T occlusion.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.123.001025
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
    detail.hit.zdb_id: 3144224-9
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  • 9
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    Abstract WP248: Developing and Validating Post-Treatment HERMES Score to Predict Outcome From Anterior Circulation Large Vessel Occlusion Stroke: A Meta-Analysis of Individual Data From 7 Randomized Clinical Trials
    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: Clinicians need simple and highly predictive prognostic scores to assist practical decision-making and family discussion. We aimed to develop and validate a simple prediction score applied at 24 hours to assist prognostication in patients with anterior circulation ischemic stroke due to large vessel occlusion. Methods: Using the HERMES collaboration dataset (n = 1764), patients in the endovascular therapy (EVT) arm were divided randomly into a derivation cohort (n = 430) and a validation cohort (n = 441). From a set of candidate predictors, forward selection using c-statistics was employed to select a model which was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in both the EVT validation cohort and in the control arm (n = 893) for mRS ≤2 and ≤3. Results: In the derivation cohort, two significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale [NIHSS] score at 24 h and age [β-coefficient 0.34 and 0.06] ) were selected. Incorporating other variables did not much improve model performance. Among models with different weights, we derived the HERMES score: age (years)/10 + NIHSS score at 24 h, based on model performance and simplicity. The HERMES score was highly predictive for mRS ≤2 in the derivation cohort, validation cohort-EVT, and control arm (c-statistics 0.907, 0.914, and 0.909, respectively). Evaluation of the score against mRS ≤3 as an alternative outcome yielded similar results (c-statistics 0.911, 0.903, and 0.885). Among 435 subjects (24.7%) with HERMES score ≥25, the observed probability was 3.1-3.4% for mRS ≤2 and 9.4-16.7% for mRS ≤3 in the derivation cohort, validation cohort-EVT, and control arm (Figure). Conclusions: The HERMES score is a simple validated score to predict outcomes in patients with anterior circulation large vessel occlusion ischemic stroke regardless of intervention. HERMES score should be helpful in prognostic discussion with families on day two.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.55.suppl_1.WP248
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2024
    detail.hit.zdb_id: 1467823-8
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