In a multicenter Chinese trial involving 656 patients with large-vessel occlusion, endovascular thrombectomy was noninferior, within a 20% margin of confidence, to endovascular thrombectomy with ...intravenous alteplase given within 4.5 hours after stroke. The incidence of intracerebral hemorrhage was similar in the two groups.
Automatic Collateral Scoring From 3D CTA Images Su, Jiahang; Wolff, Lennard; van Es, Adriaan C. G. M ...
IEEE transactions on medical imaging,
06/2020, Letnik:
39, Številka:
6
Journal Article
Odprti dostop
The collateral score is an important biomarker in decision making for endovascular treatment (EVT) of patients with ischemic stroke. The existing collateral grading systems are based on visual ...inspection and prone to subjective interpretation and interobserver variation. The purpose of our work is the development of an automatic collateral scoring method. In this work, we present a method that is inspired by human collateral scoring. Firstly, we define an anatomical region by atlas-based registration and extract vessel structures using a deep convolutional neural network. From this, high-level features based on the ratios of vessel length and volume of the occluded and the contralateral side are defined. Multi-class classification models are used to map the feature space to a four-grade collateral score and a quantitative score. The dataset used for training, validation and testing is from a registry of images acquired in clinical routine at multiple medical centers. The model performance is tested on 269 subjects, achieving an accuracy of 0.8. The dichotomized collateral score accuracy is 0.9. The error is comparable to the interobserver variation, the results are comparable to the performance of two radiologists with 10 to 30 years of experience.
BACKGROUND AND PURPOSE—Thrombus imaging characteristics have been reported to be useful to predict functional outcome and reperfusion in acute ischemic stroke. However, conflicting data about this ...subject exist in patients undergoing endovascular treatment. Therefore, we aimed to evaluate whether thrombus imaging characteristics assessed on computed tomography are associated with outcomes in patients with acute ischemic stroke treated by endovascular treatment.
METHODS—The MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, and observational study in all centers performing endovascular treatment in the Netherlands. We evaluated associations of thrombus imaging characteristics with the functional outcome (modified Rankin Scale at 90 days), mortality, reperfusion, duration of endovascular treatment, and symptomatic intracranial hemorrhage using univariable and multivariable regression models. Thrombus characteristics included location, clot burden score (CBS), length, relative and absolute attenuation, perviousness, and distance from the internal carotid artery terminus to the thrombus. All characteristics were assessed on thin-slice (≤2.5 mm) noncontrast computed tomography and computed tomography angiography, acquired within 30 minutes from each other.
RESULTS—In total, 408 patients were analyzed. Thrombus with distal location, higher CBS, and shorter length were associated with better functional outcome (adjusted common odds ratio, 3.3; 95% CI, 2.0–5.3 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted common odds ratio, 1.15; 95% CI, 1.07–1.24 per CBS point; and adjusted common odds ratio, 0.96; 95% CI, 0.94–0.99 per mm, respectively) and reduced duration of endovascular procedure (adjusted coefficient B, −14.7; 95% CI, −24.2 to −5.1 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted coefficient B, −8.5; 95% CI, −14.5 to −2.4 per CBS point; and adjusted coefficient B, 7.3; 95% CI, 2.9–11.8 per mm, respectively). Thrombus perviousness was associated with better functional outcome (adjusted common odds ratio, 1.01; 95% CI, 1.00–1.02 per Hounsfield units increase). Distal thrombi were associated with successful reperfusion (adjusted odds ratio, 2.6; 95% CI, 1.4–4.9 for proximal M1 occlusion compared with internal carotid artery occlusion).
CONCLUSIONS—Distal location, higher CBS, and shorter length are associated with better functional outcome and faster endovascular procedure. Distal thrombus is strongly associated with successful reperfusion, and a pervious thrombus is associated with better functional outcome.
In a follow-up of a trial comparing endovascular thrombectomy with conventional therapy for acute ischemic stroke, the beneficial effect on functional recovery that was observed at 90 days was ...maintained at 2 years. Quality of life was better at 2 years with endovascular treatment.
We reported previously the 90-day outcomes of a trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands MR CLEAN) in which standard treatment was compared with endovascular treatment, administered within 6 hours after the onset of acute ischemic stroke caused by an intracranial arterial occlusion of the anterior circulation.
1
Most patients in the intervention group were treated by mechanical thrombectomy with the use of retrievable stents. The trial showed that functional recovery at 90 days was better with the intervention than with standard treatment. Subsequently, the beneficial effect of mechanical thrombectomy on 90-day outcomes . . .
Outcome prognostication in traumatic brain injury (TBI) is important but challenging due to heterogeneity of the disease. The aim of this systematic review is to present the current state-of-the-art ...on prognostic models for outcome after moderate and severe TBI and evidence on their validity. We searched for studies reporting on the development, validation or extension of prognostic models for functional outcome after TBI with Glasgow Coma Scale (GCS) ≤12 published between 2006-2018. Studies with patients age ≥14 years and evaluating a multi-variable prognostic model based on admission characteristics were included. Model discrimination was expressed with the area under the receiver operating characteristic curve (AUC), and model calibration with calibration slope and intercept. We included 58 studies describing 67 different prognostic models, comprising the development of 42 models, 149 external validations of 31 models, and 12 model extensions. The most common predictors were GCS (motor) score (
= 55), age (
= 54), and pupillary reactivity (
= 48). Model discrimination varied substantially between studies. The International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) models were developed on the largest cohorts (8509 and 10,008 patients, respectively) and were most often externally validated (
= 91), yielding AUCs ranging between 0.65-0.90 and 0.66-1.00, respectively. Model calibration was reported with a calibration intercept and slope for seven models in 53 validations, and was highly variable. In conclusion, the discriminatory validity of the IMPACT and CRASH prognostic models is supported across a range of settings. The variation in calibration, reflecting heterogeneity in reliability of predictions, motivates continuous validation and updating if clinical implementation is pursued.
BACKGROUND AND PURPOSE—To assess the effect of inter-hospital transfer on time to treatment and functional outcome after endovascular treatment (EVT) for acute ischemic stroke, we compared patients ...transferred from a primary stroke center to patients directly admitted to an intervention center in a large nationwide registry.
METHODS—MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, observational study in all centers that perform EVT in the Netherlands. We included adult patients with an acute anterior circulation stroke who received EVT between March 2014 to June 2016. Primary outcome was time from arrival at the first hospital to arterial groin puncture. Secondary outcomes included the 90-day modified Rankin Scale score and functional independence (modified Rankin Scale score of 0–2).
RESULTS—In total 821/1526 patients, (54%) were transferred from a primary stroke center. Transferred patients less often had prestroke disability (227/800 28% versus 255/699 36%; P=0.02) and more often received intravenous thrombolytics (659/819 81% versus 511/704 73%; P<0.01). Time from first presentation to groin puncture was longer for transferred patients (164 versus 104 minutes; P<0.01, adjusted delay 57 minutes 95% CI, 51–62). Transferred patients had worse functional outcome (adjusted common OR, 0.75 95% CI, 0.62–0.90) and less often achieved functional independence (244/720 34% versus 289/681 42%, absolute risk difference −8.5% 95% CI, −8.7 to −8.3).
CONCLUSIONS—Interhospital transfer of patients with acute ischemic stroke is associated with delay of EVT and worse outcomes in routine clinical practice, even in a country where between-center distances are short. Direct transportation of patients potentially eligible for EVT to an intervention center may improve functional outcome.
BACKGROUND—Randomized clinical trials in selected acute ischemic stroke patients reported that for every hour delay of endovascular treatment (EVT), chances of functional independence diminish with ...up to 3.4%. These findings may not be fully generalizable to clinical practice because of strict in- and exclusion criteria in these trials. Therefore, we aim to assess the association of time to EVT with functional outcome in current, everyday clinical practice.
METHODS—The MR CLEAN Registry is an ongoing, prospective, observational study in all centers that perform EVT in the Netherlands. Data were analyzed from patients treated between March 2014 and June 2016. In the primary analysis we assessed the association of time from stroke onset to start of EVT and time from stroke onset to successful reperfusion with functional outcome (measured with the modified Rankin Scale (mRS)), by means of ordinal logistic regression.
RESULTS—We analyzed 1488 acute ischemic stroke patients who underwent EVT. An increased time to start of EVT was associated with worse functional outcome (adjusted common odds ratio = 0.83 per hour, 95% Confidence Interval0.77-0.89) and a 2.2% increase in mortality. Every hour increase from stroke onset to EVT start resulted in a 5.3% decreased probability of functional independence (mRS 0-2). In the 742 patients with successful reperfusion, every hour increase from stroke onset to reperfusion was associated with a 7.7% decreased probability of functional independence.
CONCLUSIONS—Time to EVT for acute ischemic stroke in current clinical practice is strongly associated with functional outcome. Our data suggest that this association might be even stronger than previously suggested in reports on more selected patient populations from randomized controlled trials. These findings emphasize that functional outcome of EVT patients can be greatly improved by shortening onset to treatment times.
...this was a trial with a PROBE (prospective, randomised, open, and blinded endpoint) design. ...the trial ran for 55 months, which implies a very low average inclusion rate of only five patients ...per month. ...trials that stop early for efficacy, such as TENSION, are small and report large effects that are much less likely to occur than when the trial is carried out until the end.11 Results of these trials should be considered carefully, and confirmation will be needed.
IMPORTANCE: Reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) for large-vessel intracranial occlusion. ...However, data are scarce on the association between the time from onset and reperfusion results. OBJECTIVE: To analyze the rate of reperfusion after EVT started at different intervals after symptom onset in patients with AIS. DESIGN, SETTING, AND PARTICIPANTS: We conducted a meta-analysis of individual patient data from 7 randomized trials of the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) group. This is a multicenter cohort study of the intervention arm of randomized clinical trials included in the HERMES group. Patients with anterior circulation AIS who underwent EVT for M1/M2 or intracranial carotid artery occlusion were included. Each trial enrolled patients according to its specific inclusion and exclusion criteria. Data on patients eligible but not enrolled (eg, refusals or exclusions) were not available. All analyses were performed by the HERMES biostatistical core laboratory using the pooled database. Data were analyzed between December 2010 and April 2015. MAIN OUTCOMES AND MEASURES: Successful reperfusion was defined as a modified thrombolysis in cerebral infarction score of 2b/3 at the end of the EVT procedure adjusted for age, occlusion location, pretreatment intravenous thrombolysis, and clot burden score and was analyzed in relation to different intervals (onset, emergency department arrival, imaging, and puncture) using mixed-methods logistic regression. RESULTS: Among the 728 included patients, with a mean (SD) age of 65.4 (13.5) years and of whom 345 were female (47.4%), decreases in rates of successful reperfusion defined as a thrombolysis in cerebral infarction score of 2b/3 were observed with increasing time from admission or first imaging to groin puncture. The magnitude of effect was a 22% relative reduction (odds ratio, 0.78; 95% CI, 0.64-0.95) per additional hour between admission and puncture and a 26% relative reduction (odds ratio, 0.74; 95% CI, 0.59-0.93) per additional hour between imaging and puncture. CONCLUSIONS AND RELEVANCE: Because the probability of reperfusion declined significantly with time between hospital arrival and groin puncture, we provide additional arguments for minimizing the intervals after symptom onset in anterior circulation acute ischemic stroke.
BACKGROUND AND PURPOSE:Ischemic stroke patients with large vessel occlusion (LVO) could benefit from direct transportation to an intervention center for endovascular treatment, but non-LVO patients ...need rapid IV thrombolysis in the nearest center. Our aim was to evaluate prehospital triage strategies for suspected stroke patients in the United States.
METHODS:We used a decision tree model and geographic information system to estimate outcome of suspected stroke patients transported by ambulance within 4.5 hours after symptom onset. We compared the following strategies(1) Always to nearest center, (2) American Heart Association algorithm (ie, directly to intervention center if a prehospital stroke scale suggests LVO and total driving time from scene to intervention center is <30 minutes, provided that the delay would not exclude from thrombolysis), (3) modified algorithms with a maximum additional driving time to the intervention center of <30 minutes, <60 minutes, or without time limit, and (4) always to intervention center. Primary outcome was the annual number of good outcomes, defined as modified Rankin Scale score of 0–2. The preferred strategy was the one that resulted in the best outcomes with an incremental number needed to transport to intervention center (NNTI) <100 to prevent one death or severe disability (modified Rankin Scale score of >2).
RESULTS:Nationwide implementation of the American Heart Association algorithm increased the number of good outcomes by 594 (+1.0%) compared with transportation to the nearest center. The associated number of non-LVO patients transported to the intervention center was 16 714 (NNTI 28). The modified algorithms yielded an increase of 1013 (+1.8%) to 1369 (+2.4%) good outcomes, with a NNTI varying between 28 and 32. The algorithm without time limit was preferred in the majority of states (n=32 65%), followed by the algorithm with <60 minutes delay (n=10 20%). Tailoring policies at county-level slightly reduced the total number of transportations to the intervention center (NNTI 31).
CONCLUSIONS:Prehospital triage strategies can greatly improve outcomes of the ischemic stroke population in the United States, but increase the number of non-LVO stroke patients transported to an intervention center. The current American Heart Association algorithm is suboptimal as a nationwide policy and should be modified to allow more delay when directly transporting LVO-suspected patients to an intervention center.
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