Among patients with acute ischemic stroke due to occlusions in the proximal anterior intracranial circulation, less than 40% regain functional independence when treated with intravenous tissue ...plasminogen activator (t-PA) alone. Thrombectomy with the use of a stent retriever, in addition to intravenous t-PA, increases reperfusion rates and may improve long-term functional outcome.
We randomly assigned eligible patients with stroke who were receiving or had received intravenous t-PA to continue with t-PA alone (control group) or to undergo endovascular thrombectomy with the use of a stent retriever within 6 hours after symptom onset (intervention group). Patients had confirmed occlusions in the proximal anterior intracranial circulation and an absence of large ischemic-core lesions. The primary outcome was the severity of global disability at 90 days, as assessed by means of the modified Rankin scale (with scores ranging from 0 no symptoms to 6 death).
The study was stopped early because of efficacy. At 39 centers, 196 patients underwent randomization (98 patients in each group). In the intervention group, the median time from qualifying imaging to groin puncture was 57 minutes, and the rate of substantial reperfusion at the end of the procedure was 88%. Thrombectomy with the stent retriever plus intravenous t-PA reduced disability at 90 days over the entire range of scores on the modified Rankin scale (P<0.001). The rate of functional independence (modified Rankin scale score, 0 to 2) was higher in the intervention group than in the control group (60% vs. 35%, P<0.001). There were no significant between-group differences in 90-day mortality (9% vs. 12%, P=0.50) or symptomatic intracranial hemorrhage (0% vs. 3%, P=0.12).
In patients receiving intravenous t-PA for acute ischemic stroke due to occlusions in the proximal anterior intracranial circulation, thrombectomy with a stent retriever within 6 hours after onset improved functional outcomes at 90 days. (Funded by Covidien; SWIFT PRIME ClinicalTrials.gov number, NCT01657461.).
OBJECTIVE The supplementary motor area (SMA) syndrome is a well-studied lesional model of brain plasticity involving the sensorimotor network. Patients with diffuse low-grade gliomas in the SMA may ...exhibit this syndrome after resective surgery. They experience a temporary loss of motor function, which completely resolves within 3 months. The authors used functional MRI (fMRI) resting state analysis of the sensorimotor network to investigate large-scale brain plasticity between the immediate postoperative period and 3 months' follow-up. METHODS Resting state fMRI was performed preoperatively, during the immediate postoperative period, and 3 months postoperatively in 6 patients with diffuse low-grade gliomas who underwent partial surgical excision of the SMA. Correlation analysis within the sensorimotor network was carried out on those 3 time points to study modifications of its functional connectivity. RESULTS The results showed a large-scale reorganization of the sensorimotor network. Interhemispheric connectivity was decreased in the postoperative period, and increased again during the recovery process. Connectivity between the lesion side motor area and the contralateral SMA rose to higher values than in the preoperative period. Intrahemispheric connectivity was decreased during the immediate postoperative period and had returned to preoperative values at 3 months after surgery. CONCLUSIONS These results confirm the findings reported in the existing literature on the plasticity of the SMA, showing large-scale modifications of the sensorimotor network, at both inter- and intrahemispheric levels. They suggest that interhemispheric connectivity might be a correlate of SMA syndrome recovery.
Objective
To perform an updated review of the literature on the neurological manifestations of COVID-19-infected patients
Methods
A PRISMA-guideline-based systematic review was conducted on PubMed, ...EMBASE, and SCOPUS. Series reporting neurological manifestations of COVID-19 patients were studied.
Results
39 studies and 68,361 laboratory-confirmed COVID-19 patients were included. Up to 21.3% of COVID-19 patients presented neurological symptoms. Headache (5.4%), skeletal muscle injury (5.1%), psychiatric disorders (4.6%), impaired consciousness (2.8%), gustatory/olfactory dysfunction (2.3%), acute cerebrovascular events (1.4%), and dizziness (1.3%), were the most frequently reported neurological manifestations. Ischemic stroke occurred among 1.3% of COVID-19 patients. Other less common neurological manifestations were cranial nerve impairment (0.6%), nerve root and plexus disorders (0.4%), epilepsy (0.7%), and hemorrhagic stroke (0.15%). Impaired consciousness and acute cerebrovascular events were reported in 14% and 4% of patients with a severe disease, respectively, and they were significantly higher compared to non-severe patients (
p
< 0.05). Individual patient data from 129 COVID-19 patients with acute ischemic stroke (AIS) were extracted: mean age was 64.4 (SD ± 6.2), 78.5% had anterior circulation occlusions, the mean NIHSS was 15 (SD ± 7), and the intra-hospital mortality rate was 22.8%. Admission to the intensive care unit (ICU) was required among 63% of patients.
Conclusion
This updated review of literature, shows that headache, skeletal muscle injury, psychiatric disorders, impaired consciousness, and gustatory/olfactory dysfunction were the most common neurological symptoms of COVID-19 patients. Impaired consciousness and acute cerebrovascular events were significantly higher among patients with a severe infection. AIS patients required ICU admission in 63% of cases, while intra-hospital mortality rate was close to 23%.
Acetylcholinesterase inhibitors are approved drugs currently used for the treatment of Alzheimer's disease (AD) dementia. Basal forebrain cholinergic system (BFCS) atrophy is reported to precede both ...entorhinal cortex atrophy and memory impairment in AD, challenging the traditional model of the temporal sequence of topographical pathology associated with AD. We studied the effect of one-year Donepezil treatment on the rate of BFCS atrophy in prodromal AD patients using a double-blind, randomized, placebo-controlled trial of Donepezil (10 mg/day). Reduced annual BFCS rates of atrophy were found in the Donepezil group compared to the Placebo treated arm. Secondary analyses on BFCS subregions demonstrated the largest treatment effects in the Nucleus Basalis of Meynert (NbM) and the medial septum/diagonal band (Ch1/2). Donepezil administered at a prodromal stage of AD seems to substantially reduce the rate of atrophy of the BFCS nuclei with highest concentration of cholinergic neurons projecting to the cortex (NbM), hippocampus and entorhinal cortex (Ch1/2).
Objective
Within the context of a prospective randomized trial (SWIFT PRIME), we assessed whether early imaging of stroke patients, primarily with computed tomography (CT) perfusion, can estimate the ...size of the irreversibly injured ischemic core and the volume of critically hypoperfused tissue. We also evaluated the accuracy of ischemic core and hypoperfusion volumes for predicting infarct volume in patients with the target mismatch profile.
Methods
Baseline ischemic core and hypoperfusion volumes were assessed prior to randomized treatment with intravenous (IV) tissue plasminogen activator (tPA) alone versus IV tPA + endovascular therapy (Solitaire stent‐retriever) using RAPID automated postprocessing software. Reperfusion was assessed with angiographic Thrombolysis in Cerebral Infarction scores at the end of the procedure (endovascular group) and Tmax > 6‐second volumes at 27 hours (both groups). Infarct volume was assessed at 27 hours on noncontrast CT or magnetic resonance imaging (MRI).
Results
A total of 151 patients with baseline imaging with CT perfusion (79%) or multimodal MRI (21%) were included. The median baseline ischemic core volume was 6ml (interquartile range = 0–16). Ischemic core volumes correlated with 27‐hour infarct volumes in patients who achieved reperfusion (r = 0.58, p < 0.0001). In patients who did not reperfuse (<10% reperfusion), baseline Tmax > 6‐second lesion volumes correlated with 27‐hour infarct volume (r = 0.78, p = 0.005). In target mismatch patients, the union of baseline core and early follow‐up Tmax > 6‐second volume (ie, predicted infarct volume) correlated with the 27‐hour infarct volume (r = 0.73, p < 0.0001); the median absolute difference between the observed and predicted volume was 13ml.
Interpretation
Ischemic core and hypoperfusion volumes, obtained primarily from CT perfusion scans, predict 27‐hour infarct volume in acute stroke patients who were treated with reperfusion therapies. ANN NEUROL 2016;79:76–89
Placement of flow-diverters across the ostia of major ICA branches carries a risk of arterial occlusion. We determined the rate of occlusion of the supraclinoid ICA branches and the related symptoms, ...following coverage with flow-diverters.
A systematic search was performed in PubMed, MEDLINE, and EMBASE. We selected studies reporting treatments with flow-diverters in which the device was placed across the ostium of the OphtA, PcomA, or AchorA. Random-effects meta-analysis was used to pool the following outcomes: rate of arterial occlusion, diminished flow, incidence of related symptoms, factors associated with arterial occlusion.
Twenty-one studies evaluating 1152 supraclinoid ICA branches were included in the meta-analysis. The incidence of OphtA occlusion and associated symptoms was 5.9% (95 CI% = 3.1–8.6%) (incidence rate = 6% per patient-year), and 0.8% (95% CI = 0.1–1.4%) (incidence rate = 0.8% per patient-year), respectively. Although asymptomatic in all cases, PcomA showed a higher occlusion rate (20.7%, 95% CI = 8.9–32.4%) (incidence rate = 19.5% per patient-year). AchorA was occluded in 1% (95% CI = 0.3–2.4%) of cases, with approximately 1% (95% CI = 0.4–2.3%) of transient neurological symptoms (incidence rate = 0.96% per patient-year). There was a trend toward higher odds of arterial patency among arteries arising from the aneurysm (OR = 2.94, P = 0.06). Demographic factors and multiple stents were not associated with higher risk of arterial impairment. Adequate collateral circulation was reported in 94.5% of patients with arterial occlusion.
During aneurysm treatment, the ostium of the supraclinoid ICA branches can be covered with flow-diverter devices with low rates of neurological symptoms related to arterial occlusion.
Objectives
To establish whether imaging assessments of irreversibly injured ischemic core and potentially salvageable penumbral volumes and collateral circulation were associated with functional ...outcome in nonagenarians (90 years or older) undergoing endovascular thrombectomy (EVT).
Methods
Data from a prospectively maintained institutional registry of consecutive stroke patients treated with EVT from January 2012 to December 2018 were retrospectively analyzed. Functional outcome was evaluated with the modified Rankin scale (mRS) at 3 months. mRS score of 0–3 was defined as a good clinical outcome. Ischemic core and penumbral volumes were calculated using the RAPID software. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)–Alberta Stroke Program Early CT Score (ASPECTS) rating system.
Results
Among 85 patients (age, 92.4 ± 2.6 years; men, 30.6%) treated with EVT, good outcome (mRS 0–3) was achieved in 29 (34.1%) patients and 31 (36.5%) patients died at 90 days. The median estimated ischemic core volume was 15 mL (IQR, 7–27 mL). The median mismatch volume was 83 mL (IQR, 43–120 mL). The median FVH score was 4 (IQR, 3–4). FVH score was independently associated with good functional outcome (adjusted OR = 1.96 95% CI, 1.16–3.32;
p
= 0.01 per 1-point increase) and mortality (adjusted OR = 0.54 95% CI, 0.34–0.85;
p
= 0.007 per 1-point increase). Ischemic core and mismatch volumes were associated with neither good outcome nor mortality.
Conclusions
In nonagenarians with anterior circulation large-vessel ischemic stroke, good collaterals as measured by the FVH–ASPECTS rating system are independently associated with improved outcomes and may help select patients for reperfusion therapy in this frail population.
Key Points
• Endovascular thrombectomy can allow at least 1 in 3 patients older than 90 years of age to achieve good functional outcome (modified Rankin scale of 0–3) at 3 months.
• Functional outcome at 3 months is associated with pre-stroke status (number and severity of patients’ comorbidities).
• A higher FVH score (as reflected by higher FLAIR vascular hyperintensity FVH–Alberta Stroke Program Early CT Score ASPECTS values) is independently associated with better 3-month functional outcome and mortality in nonagenarians with anterior circulation ischemic stroke.
Clinical trials have demonstrated improved 90-day outcomes for patients with acute ischemic stroke treated with stent retriever thrombectomy plus tissue-type plasminogen activator (SST+tPA) compared ...with tPA. Previous studies suggested that this strategy may be cost-effective, but models were derived from pooled data and older assumptions.
In this prospective economic substudy conducted alongside the SWIFT-PRIME trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke), in-trial costs were measured for patients using detailed medical resource utilization and hospital billing data. Utility weights were assessed at 30 and 90 days using the EuroQol-5 dimension questionnaire. Post-trial costs and life-expectancy were estimated for each surviving patient using a model based on trial data and inputs derived from a contemporary cohort of ischemic stroke survivors.
Index hospitalization costs were $17 183 per patient higher for SST+tPA than for tPA ($45 761 versus $28 578; P<0.001), driven by initial procedure costs. Between discharge and 90 days, costs were $4904 per patient lower for SST+tPA than for tPA ($11 270 versus $16 174; P=0.014); total 90-day costs remained higher with SST+tPA ($57 031 versus $44 752; P<0.001). Higher utility values for SST+tPA led to higher in-trial quality-adjusted life years (0.131 versus 0.105; P=0.005). In lifetime projections, SST+tPA was associated with substantial gains in quality-adjusted life years (6.79 versus 5.05), cost savings of $23 203 per patient and was economically dominant when compared with tPA in 90% of bootstrap replicates.
Among patients with acute ischemic stroke enrolled in the SWIFT-PRIME trial, SST increased initial treatment costs, but was projected to improve quality-adjusted life-expectancy and reduce healthcare costs over a lifetime horizon compared with tPA.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.
The majority of patients enrolled in SWIFT PRIME trial (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke) had computed tomographic ...perfusion (CTP) imaging before randomization; 34 patients were randomized after magnetic resonance imaging (MRI).
Patients with middle cerebral artery and distal carotid occlusions were randomized to treatment with tPA (tissue-type plasminogen activator) alone or tPA+stentriever thrombectomy. The primary outcome was the distribution of the modified Rankin Scale score at 90 days. Patients with the target mismatch profile for enrollment were identified on MRI and CTP.
MRI selection was performed in 34 patients; CTP in 139 patients. Baseline National Institutes of Health Stroke Scale score was 17 in both groups. Target mismatch profile was present in 95% (MRI) versus 83% (CTP). A higher percentage of the MRI group was transferred from an outside hospital (
=0.02), and therefore, the time from stroke onset to randomization was longer in the MRI group (
=0.003). Time from emergency room arrival to randomization did not differ in CTP versus MRI-selected patients. Baseline ischemic core volumes were similar in both groups. Reperfusion rates (>90%/TICI Thrombolysis in Cerebral Infarction score 3) did not differ in the stentriever-treated patients in the MRI versus CTP groups. The primary efficacy analysis (90-day mRS score) demonstrated a statistically significant benefit in both subgroups (MRI,
=0.02; CTP,
=0.01). Infarct growth was reduced in the stentriever-treated group in both MRI and CTP groups.
Time to randomization was significantly longer in MRI-selected patients; however, site arrival to randomization times were not prolonged, and the benefits of endovascular therapy were similar.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.
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