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  • 1
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    Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles
    American Medical Association (AMA) ; 2024
    In:  JAMA Vol. 331, No. 9 ( 2024-03-05), p. 750-
    Details
    In: JAMA, American Medical Association (AMA), Vol. 331, No. 9 ( 2024-03-05), p. 750-
    Abstract: Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain. Objective To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect. Design, Setting, and Participants An exploratory analysis of the SELECT2 trial, which randomized 352 adults (18-85 years) with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) and large ischemic core to EVT vs medical management (MM), across 31 global centers between October 2019 and September 2022. Intervention EVT vs MM. Main Outcomes and Measures Primary outcome was functional outcome—90-day mRS score (0, no symptoms, to 6, death) assessed by adjusted generalized OR (aGenOR; values & amp;gt;1 represent more favorable outcomes). Benefit of EVT vs MM was assessed across levels of ischemic injury defined by noncontrast CT using ASPECTS score and by the volume of brain with severely reduced blood flow on CT perfusion or restricted diffusion on MRI. Results Among 352 patients randomized, 336 were analyzed (median age, 67 years; 139 [41.4%] female); of these, 168 (50%) were randomized to EVT, and 2 additional crossover MM patients received EVT. In an ordinal analysis of mRS at 90 days, EVT improved functional outcomes compared with MM within ASPECTS categories of 3 (aGenOR, 1.71 [95% CI, 1.04-2.81] ), 4 (aGenOR, 2.01 [95% CI, 1.19-3.40]), and 5 (aGenOR, 1.85 [95% CI, 1.22-2.79] ). Across strata for CT perfusion/MRI ischemic core volumes, aGenOR for EVT vs MM was 1.63 (95% CI, 1.23-2.16) for volumes ≥70 mL, 1.41 (95% CI, 0.99-2.02) for ≥100 mL, and 1.47 (95% CI, 0.84-2.56) for ≥150 mL. In the EVT group, outcomes worsened as ASPECTS decreased (aGenOR, 0.91 [95% CI, 0.82-1.00] per 1-point decrease) and as CT perfusion/MRI ischemic core volume increased (aGenOR, 0.92 [95% CI, 0.89-0.95] per 10-mL increase). No heterogeneity of EVT treatment effect was observed with or without mismatch, although few patients without mismatch were enrolled. Conclusion and Relevance In this exploratory analysis of a randomized clinical trial of patients with extensive ischemic stroke, EVT improved clinical outcomes across a wide spectrum of infarct volumes, although enrollment of patients with minimal penumbra volume was low. In EVT-treated patients, clinical outcomes worsened as presenting ischemic injury estimates increased. Trial Registration ClinicalTrials.gov Identifier: NCT03876457
    Type of Medium: Online Resource
    ISSN: 0098-7484
    URL: Article
    DOI: 10.1001/jama.2024.0572
    RVK:
    XA 10000
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2024
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    SSG: 5,21
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  • 2
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    Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes : A Prespecified Analysis of the SELECT2 Trial
    American Medical Association (AMA) ; 2024
    In:  JAMA Neurology Vol. 81, No. 4 ( 2024-04-01), p. 327-
    Details
    In: JAMA Neurology, American Medical Association (AMA), Vol. 81, No. 4 ( 2024-04-01), p. 327-
    Abstract: Patients with large ischemic core stroke have poor clinical outcomes and are frequently not considered for interfacility transfer for endovascular thrombectomy (EVT). Objective To assess EVT treatment effects in transferred vs directly presenting patients and to evaluate the association between transfer times and neuroimaging changes with EVT clinical outcomes. Design, Setting, and Participants This prespecified secondary analysis of the SELECT2 trial, which evaluated EVT vs medical management (MM) in patients with large ischemic stroke, evaluated adults aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) as well as an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5, core of 50 mL or greater on imaging, or both. Patients were enrolled between October 2019 and September 2022 from 31 EVT-capable centers in the US, Canada, Europe, Australia, and New Zealand. Data were analyzed from August 2023 to January 2024. Interventions EVT vs MM. Main Outcomes and Measures Functional outcome, defined as modified Rankin Scale (mRS) score at 90 days with blinded adjudication. Results A total of 958 patients were screened and 606 patients were excluded. Of 352 enrolled patients, 145 (41.2%) were female, and the median (IQR) age was 66.5 (58-75) years. A total of 211 patients (59.9%) were transfers, while 141 (40.1%) presented directly. The median (IQR) transfer time was 178 (136-230) minutes. The median (IQR) ASPECTS decreased from the referring hospital (5 [4-7]) to an EVT-capable center (4 [3-5] ). Thrombectomy treatment effect was observed in both directly presenting patients (adjusted generalized odds ratio [OR], 2.01; 95% CI, 1.42-2.86) and transferred patients (adjusted generalized OR, 1.50; 95% CI, 1.11-2.03) without heterogeneity ( P for interaction = .14). Treatment effect point estimates favored EVT among 82 transferred patients with a referral hospital ASPECTS of 5 or less (44 received EVT; adjusted generalized OR, 1.52; 95% CI, 0.89-2.58). ASPECTS loss was associated with numerically worse EVT outcomes (adjusted generalized OR per 1-ASPECTS point loss, 0.89; 95% CI, 0.77-1.02). EVT treatment effect estimates were lower in patients with transfer times of 3 hours or more (adjusted generalized OR, 1.15; 95% CI, 0.73-1.80). Conclusions and Relevance Both directly presenting and transferred patients with large ischemic stroke in the SELECT2 trial benefited from EVT, including those with low ASPECTS at referring hospitals. However, the association of EVT with better functional outcomes was numerically better in patients presenting directly to EVT-capable centers. Prolonged transfer times and evolution of ischemic change were associated with worse EVT outcomes. These findings emphasize the need for rapid identification of patients suitable for transfer and expedited transport. Trial Registration ClinicalTrials.gov Identifier: NCT03876457
    Type of Medium: Online Resource
    ISSN: 2168-6149
    URL: Article
    DOI: 10.1001/jamaneurol.2024.0206
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2024
    detail.hit.zdb_id: 2702023-X
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  • 3
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    Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well : The SELECT Late Study
    American Medical Association (AMA) ; 2023
    In:  JAMA Neurology Vol. 80, No. 2 ( 2023-02-01), p. 172-
    Details
    In: JAMA Neurology, American Medical Association (AMA), Vol. 80, No. 2 ( 2023-02-01), p. 172-
    Abstract: The role of endovascular thrombectomy is uncertain for patients presenting beyond 24 hours of the time they were last known well. Objective To evaluate functional and safety outcomes for endovascular thrombectomy (EVT) vs medical management in patients with large-vessel occlusion beyond 24 hours of last known well. Design, Setting, and Participants This retrospective observational cohort study enrolled patients between July 2012 and December 2021 at 17 centers across the United States, Spain, Australia, and New Zealand. Eligible patients had occlusions in the internal carotid artery or middle cerebral artery (M1 or M2 segment) and were treated with EVT or medical management beyond 24 hours of last known well. Interventions Endovascular thrombectomy or medical management (control). Main Outcomes and Measures Primary outcome was functional independence (modified Rankin Scale score 0-2). Mortality and symptomatic intracranial hemorrhage (sICH) were safety outcomes. Propensity score (PS)–weighted multivariable logistic regression analyses were adjusted for prespecified clinical characteristics, perfusion parameters, and/or Alberta Stroke Program Early CT Score (ASPECTS) and were repeated in subsequent 1:1 PS-matched cohorts. Results Of 301 patients (median [IQR] age, 69 years [59-81] ; 149 female), 185 patients (61%) received EVT and 116 (39%) received medical management. In adjusted analyses, EVT was associated with better functional independence (38% vs control, 10%; inverse probability treatment weighting adjusted odds ratio [IPTW aOR], 4.56; 95% CI, 2.28-9.09; P   & amp;lt; .001) despite increased odds of sICH (10.1% for EVT vs 1.7% for control; IPTW aOR, 10.65; 95% CI, 2.19-51.69; P  = .003). This association persisted after PS-based matching on (1) clinical characteristics and ASPECTS (EVT, 35%, vs control, 19%; aOR, 3.14; 95% CI, 1.02-9.72; P  = .047); (2) clinical characteristics and perfusion parameters (EVT, 35%, vs control, 17%; aOR, 4.17; 95% CI, 1.15-15.17; P  = .03); and (3) clinical characteristics, ASPECTS, and perfusion parameters (EVT, 45%, vs control, 21%; aOR, 4.39; 95% CI, 1.04-18.53; P  = .04). Patients receiving EVT had lower odds of mortality (26%) compared with those in the control group (41%; IPTW aOR, 0.49; 95% CI, 0.27-0.89; P  = .02). Conclusions and Relevance In this study of treatment beyond 24 hours of last known well, EVT was associated with higher odds of functional independence compared with medical management, with consistent results obtained in PS-matched subpopulations and patients with presence of mismatch, despite increased odds of sICH. Our findings support EVT feasibility in selected patients beyond 24 hours. Prospective studies are warranted for confirmation.
    Type of Medium: Online Resource
    ISSN: 2168-6149
    URL: Article
    DOI: 10.1001/jamaneurol.2022.4714
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2023
    detail.hit.zdb_id: 2702023-X
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  • 4
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    Abstract 36: Endovascular Thrombectomy Beyond 24 Hours From Last Known Well: A Pooled Multicenter International Cohort
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. Suppl_1 ( 2022-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. Suppl_1 ( 2022-02)
    Abstract: Background: Limited data are available on endovascular thrombectomy (EVT) efficacy and safety in large vessel occlusion (LVO) patients presenting 〉 24hr from last known well (LKW). We compared outcomes between patients receiving EVT and best medical management (MM) in a multicenter international cohort. Methods: Consecutive patients with anterior circulation LVO presenting 〉 24h after LKW from 13 centers from 7/2012-4/2021 were analyzed. Multivariable models for 90d mRS distribution and symptomatic ICH were adjusted for age, NIHSS, glucose, IV tPA, transfer status, clot location, time from LKW, CT ASPECTS and ischemic core (rCBF 〈 30%) and Tmax 〉 6s volumes. Results: Of 240 patients with a median (IQR) LKW to presentation 28.3h (24.9-38.2), 153 (64%) received EVT. Baseline characteristics were similar except for NIHSS (EVT: 13 (8-20) vs MM: 17 (10-22), p=0.005), CT ASPECTS (EVT: 8(6-9) vs MM: 4(3-6), p 〈 0.001) and ischemic core 2.5(0-13) vs 15(0-71) mL, p 〈 0.001. EVT was associated with a better shift in 90d mRS (acOR: 2.45, 95% CI=1.42-4.22, p=0.001), higher functional independence (42% vs 10%, aOR: 4.84, 95% CI=2.02-11.64, p 〈 0.001) and numerically lower mortality (22% vs 42%, aOR: 0.50, 95% CI=0.23-1.06, p=0.071), Fig 1A. However, EVT was associated with numerically higher sICH (5.5% vs 0%, p=0.10). Following EVT, 82% achieved successful reperfusion (mTICI 2b-3), which was associated with better shift in 90d mRS (acOR: 5.82, 95% CI: 1.77-19.10, p=0.004), higher functional independence (44% vs 22%, aOR: 5.03, 95% CI: 0.87-29.12, p=0.07) and lower mortality (20% vs 52%, aOR: 0.08, 95% CI: 0.01-0.57, p=0.01), Fig 1B. Conclusions: EVT may be associated with better functional outcomes, despite numerically increased risk of sICH in patients presenting with anterior circulation LVO beyond 24 hours. Further prospective studies are warranted.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.53.suppl_1.36
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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    detail.hit.zdb_id: 1467823-8
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  • 5
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    Procedural and biophysical indicators of durable pulmonary vein isolation during cryoballoon ablation of atrial fibrillation
    Elsevier BV ; 2016
    In:  Heart Rhythm Vol. 13, No. 2 ( 2016-02), p. 424-432
    Details
    In: Heart Rhythm, Elsevier BV, Vol. 13, No. 2 ( 2016-02), p. 424-432
    Type of Medium: Online Resource
    ISSN: 1547-5271
    URL: Article
    DOI: 10.1016/j.hrthm.2015.10.033
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2016
    detail.hit.zdb_id: 2229357-7
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  • 6
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    Pulmonary vein reconnection following catheter ablation of atrial fibrillation using the second-generation cryoballoon versus open-irrigated radiofrequency: results of a multicenter analysis
    Springer Science and Business Media LLC ; 2016
    In:  Journal of Interventional Cardiac Electrophysiology Vol. 47, No. 3 ( 2016-12), p. 341-348
    Details
    In: Journal of Interventional Cardiac Electrophysiology, Springer Science and Business Media LLC, Vol. 47, No. 3 ( 2016-12), p. 341-348
    Type of Medium: Online Resource
    ISSN: 1383-875X , 1572-8595
    URL: Article
    DOI: 10.1007/s10840-016-0172-z
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2016
    detail.hit.zdb_id: 1329179-8
    detail.hit.zdb_id: 2006887-6
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  • 7
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    Acute and Long‐Term Outcomes of Catheter Ablation of Atrial Fibrillation Using the Second‐Generation Cryoballoon versus Open‐Irrigated Radiofrequency: A Multicenter Experience
    Wiley ; 2015
    In:  Journal of Cardiovascular Electrophysiology Vol. 26, No. 8 ( 2015-08), p. 832-839
    Details
    In: Journal of Cardiovascular Electrophysiology, Wiley, Vol. 26, No. 8 ( 2015-08), p. 832-839
    Abstract: There are limited comparative data on catheter ablation of atrial fibrillation (CAAF) using the second‐generation cryoballoon (CB‐2) versus point‐by‐point radiofrequency (RF). This study examines the acute/long‐term CAAF outcomes using these 2 strategies. Methods and Results In this multicenter, retrospective, nonrandomized analysis, procedural and clinical outcomes of 1,196 patients (76% with paroxysmal AF) undergoing CAAF using CB‐2 (n = 773) and open‐irrigated, non‐force sensing RF (n = 423) were evaluated. Pulmonary vein isolation was achieved in 98% with CB‐2 and 99% with RF (P = 0.168). CB‐2 was associated with shorter ablation time (40 ± 14 min vs. 66 ± 26 min; P 〈 0.001) and procedure time (145 ± 49 minutes vs. 188 ± 42 minutes; P 〈 0.001), but greater fluoroscopic utilization (29 ± 13 minutes vs. 23 ± 14 minutes; P 〈 0.001). While transient (7.6% vs. 0%; P 〈 0.001) and persistent (1.2% vs. 0%; P = 0.026) phrenic nerve palsy occurred exclusively with CB‐2, other adverse event rates were similar between CB‐2 (1.6%) and RF (2.6%); P = 0.207. However, freedom from AF/atrial flutter/tachycardia at 12 months following a single procedure without antiarrhythmic therapy was greater with CB‐2 (76.6%) versus RF (60.4%); P 〈 0.001. While this difference was evident in patients with paroxysmal AF (P 〈 0.001), it did not reach significance in those with persistent AF (P = 0.089). Additionally, CB‐2 was associated with reduced long‐term need for antiarrhythmic therapy (16.7% vs. 22.0%; P = 0.024) and repeat ablations (14.6% vs. 24.1%; P 〈 0.001). Conclusion In this multicenter, retrospective, nonrandomized study, CAAF using CB‐2 coupled with RF as occasionally required was associated with greater freedom from atrial arrhythmias at 12 months following a single procedure without antiarrhythmic therapy when compared to open‐irrigated, non‐force sensing RF, alone.
    Type of Medium: Online Resource
    ISSN: 1045-3873 , 1540-8167
    URL: Issue
    URL: Article
    DOI: 10.1111/jce.2015.26.issue-8
    DOI: 10.1111/jce.12695
    Language: English
    Publisher: Wiley
    Publication Date: 2015
    detail.hit.zdb_id: 1025989-2
    detail.hit.zdb_id: 2037519-0
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  • 8
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    Impact of irrigation flow rate and intrapericardial fluid on cooled-tip epicardial radiofrequency ablation
    Elsevier BV ; 2016
    In:  Heart Rhythm Vol. 13, No. 8 ( 2016-08), p. 1602-1611
    Details
    In: Heart Rhythm, Elsevier BV, Vol. 13, No. 8 ( 2016-08), p. 1602-1611
    Type of Medium: Online Resource
    ISSN: 1547-5271
    URL: Article
    DOI: 10.1016/j.hrthm.2016.05.008
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2016
    detail.hit.zdb_id: 2229357-7
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  • 9
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    Mediation of Successful Reperfusion Effect through Infarct Growth and Cerebral Edema: A Pooled, Patient‐Level Analysis of EXTEND‐IA Trials and SELECT Prospective Cohort
    Wiley ; 2023
    In:  Annals of Neurology Vol. 93, No. 4 ( 2023-04), p. 793-804
    Details
    In: Annals of Neurology, Wiley, Vol. 93, No. 4 ( 2023-04), p. 793-804
    Abstract: Reperfusion therapy is highly beneficial for ischemic stroke. Reduction in both infarct growth and edema are plausible mediators of clinical benefit with reperfusion. We aimed to quantify these mediators and their interrelationship. Methods In a pooled, patient‐level analysis of the EXTEND‐IA trials and SELECT study, we used a mediation analysis framework to quantify infarct growth and cerebral edema (midline shift) mediation effect on successful reperfusion (modified Treatment in Cerebral Ischemia ≥ 2b) association with functional outcome (modified Rankin Scale distribution). Furthermore, we evaluated an additional pathway to the original hypothesis, where infarct growth mediated successful reperfusion effect on midline shift. Results A total 542 of 665 (81.5%) eligible patients achieved successful reperfusion. Baseline clinical and imaging characteristics were largely similar between those achieving successful versus unsuccessful reperfusion. Median infarct growth was 12.3ml (interquartile range [IQR] = 1.8–48.4), and median midline shift was 0mm (IQR = 0–2.2). Of 249 (37%) demonstrating a midline shift of ≥1mm, median shift was 2.75mm (IQR = 1.89–4.21). Successful reperfusion was associated with reductions in both predefined mediators, infarct growth (β = −1.19, 95% confidence interval [CI] = −1.51 to −0.88, p   〈  0.001) and midline shift (adjusted odds ratio = 0.36, 95% CI = 0.23–0.57, p   〈  0.001). Successful reperfusion association with improved functional outcome (adjusted common odds ratio [acOR] = 2.68, 95% CI = 1.86–3.88, p   〈  0.001) became insignificant (acOR = 1.39, 95% CI = 0.95–2.04, p  = 0.094) when infarct growth and midline shift were added to the regression model. Infarct growth and midline shift explained 45% and 34% of successful reperfusion effect, respectively. Analysis considering an alternative hypothesis demonstrated consistent results. Interpretation In this mediation analysis from a pooled, patient‐level cohort, a significant proportion (~80%) of successful reperfusion effect on functional outcome was mediated through reduction in infarct growth and cerebral edema. Further studies are required to confirm our findings, detect additional mediators to explain successful reperfusion residual effect, and identify novel therapeutic targets to further enhance reperfusion benefits. ANN NEUROL 2023;93:793–804
    Type of Medium: Online Resource
    ISSN: 0364-5134 , 1531-8249
    URL: Issue
    URL: Article
    DOI: 10.1002/ana.v93.4
    DOI: 10.1002/ana.26587
    Language: English
    Publisher: Wiley
    Publication Date: 2023
    detail.hit.zdb_id: 80362-5
    detail.hit.zdb_id: 2037912-2
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  • 10
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    Current State of Evidence for Neuroimaging Paradigms in Management of Acute Ischemic Stroke
    Wiley ; 2024
    In:  Annals of Neurology Vol. 95, No. 6 ( 2024-06), p. 1017-1034
    Details
    In: Annals of Neurology, Wiley, Vol. 95, No. 6 ( 2024-06), p. 1017-1034
    Abstract: Stroke is the chief differential diagnosis in patient presenting to the emergency room with abrupt onset focal neurological deficits. Neuroimaging, including non‐contrast computed tomography (CT), magnetic resonance imaging (MRI), vascular and perfusion imaging, is a cornerstone in the diagnosis and treatment decision‐making. This review examines the current state of evidence behind the different imaging paradigms for acute ischemic stroke diagnosis and treatment, including current recommendations from the guidelines. Non‐contrast CT brain, or in some centers MRI, can help differentiate ischemic stroke and intracerebral hemorrhage (ICH), a pivotal juncture in stroke diagnosis and treatment algorithm, especially for early window thrombolytics. Advanced imaging such as MRI or perfusion imaging can also assist making a diagnosis of ischemic stroke versus mimics such as migraine, Todd's paresis, or functional disorders. Identification of medium‐large vessel occlusions with CT or MR angiography triggers consideration of endovascular thrombectomy (EVT), with additional perfusion imaging help identify salvageable brain tissue in patients who are likely to benefit from reperfusion therapies, particularly in the ≥6 h window. We also review recent advances in neuroimaging and ongoing trials in key therapeutic areas and their imaging selection criteria to inform the readers on potential future transitions into use of neuroimaging for stroke diagnosis and treatment decision making. ANN NEUROL 2024;95:1017–1034
    Type of Medium: Online Resource
    ISSN: 0364-5134 , 1531-8249
    URL: Issue
    URL: Article
    DOI: 10.1002/ana.v95.6
    DOI: 10.1002/ana.26925
    Language: English
    Publisher: Wiley
    Publication Date: 2024
    detail.hit.zdb_id: 80362-5
    detail.hit.zdb_id: 2037912-2
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