Whether endovascular therapy (EVT) added on best medical management (BMM), as compared to BMM alone, is beneficial in acute ischemic stroke with isolated posterior cerebral artery occlusion is ...unknown.
We conducted a multicenter international observational study of consecutive stroke patients admitted within 6 hours from symptoms onset in 26 stroke centers with isolated occlusion of the first (P1) or second (P2) segment of the posterior cerebral artery and treated either with BMM+EVT or BMM alone. Propensity score with inverse probability of treatment weighting was used to account for baseline between-groups differences. The primary outcome was 3-month good functional outcome (modified Rankin Scale mRS score 0-2 or return to baseline modified Rankin Scale). Secondary outcomes were 3-month excellent recovery (modified Rankin Scale score 0-1), symptomatic intracranial hemorrhage, and early neurological deterioration.
Overall, 752 patients were included (167 and 585 patients in the BMM+EVT and BMM alone groups, respectively). Median age was 74 (interquartile range, 63-82) years, 329 (44%) patients were female, median National Institutes of Health Stroke Scale was 6 (interquartile range 4-10), and occlusion site was P1 in 188 (25%) and P2 in 564 (75%) patients. Baseline clinical and radiological data were similar between the 2 groups following propensity score weighting. EVT was associated with a trend towards lower odds of good functional outcome (odds ratio, 0.81 95% CI, 0.66-1.01;
=0.06) and was not associated with excellent functional outcome (odds ratio, 1.17 95% CI, 0.95-1.43;
=0.15). EVT was associated with a higher risk of symptomatic intracranial hemorrhage (odds ratio, 2.51 95% CI, 1.35-4.67;
=0.004) and early neurological deterioration (odds ratio, 2.51 95% CI, 1.64-3.84;
<0.0001).
In this observational study of patients with proximal posterior cerebral artery occlusion, EVT was not associated with good or excellent functional outcome as compared to BMM alone. However, EVT was associated with higher rates of symptomatic intracranial hemorrhage and early neurological deterioration. EVT should not be routinely recommended in this population, but randomization into a clinical trial is highly warranted.
Background
High-flow extracranial-intracranial bypass is associated with a significant risk of ischemic stroke. The goal of this study is to evaluate the effectiveness of STA-MCA bypass preceding a ...high-flow bypass as a means of protecting the brain from ischemia during the high-flow bypass anastomosis in patients with otherwise untreatable aneurysms.
Materials and method
This prospective study included 10 consecutive patients treated for complex/giant aneurysm using a previous combined STA-MCA bypass and high-flow EC-IC bypass between June 2016 and January 2018 when classical endovascular or microsurgical exclusion was estimated too risky. Early cranial Doppler, MRI, CT scan, and conventional angiography were performed in each patient to confirm patency of bypasses, measure flow in the anastomoses, detect any ischemic lesions, and evaluate exclusion of the aneurysm.
Results
The mean age at treatment was 55 years (range 34 to 67). The mean time of microsurgical procedure was 11 h (range 9 to 12). In all patients, the high-flow bypass was patent intraoperatively and complete occlusion of aneurysm was obtained. No ischemic lesions were noted on early MRI. One patient died from a large hemispheric infarction related to a common carotid artery dissection 10 days after the microsurgical procedure and immediate postoperative epidural hematoma was noted in one other patient.
Conclusion
In this study, we described the use of a protective STA-MCA bypass, performed prior to the high-flow bypass, in order to reduce the risk of perioperative ischemic lesions without increasing the morbidity of the surgical procedure. This treatment paradigm was feasible in all ten patients without complications related to the STA-MCA anastomosis.
The adequacy of leptomeningeal collateral flow has a pivotal role in determining clinical outcome in acute ischemic stroke. The American Society of Interventional and Therapeutic ...Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral score is among the most commonly used scales for measuring this flow. It is based on the extent and rate of retrograde collateral flow to the impaired territory on angiography.
To evaluate inter- and intraobserver agreementin angiographic leptomeningeal collateral flow assessment.
Thirty pretreatment angiogram video loops (frontal and lateral view), chosen from the randomized controlled trial THRombectomie des Artères CErebrales (THRACE), were sent for grading in an electronic file. 19 readers participated, including eight who had access to a training set before the first grading. 13 readers made a double evaluation, 3 months apart.
Overall agreement among the 19 observers was poor (κ = 0,16 ± 6,5.10
), and not improved with prior training (κ = 0,14 ± 0,016). Grade 4 showed the poorest interobserver agreement (κ=0.18±0.002) while grades 0 and 1 were associated with the best results (κ=0.52±0.001 and κ=0.43±0.004, respectively). Interobserver agreement increased (κ = 0,27± 0,014) when a dichotomized score, 'poor collaterals' (score of 0, 1 or 2) versus 'good collaterals' (score of 3 or 4) was used. The intraobserver agreements varied between slight (κ=0.18±0.13) and substantial (κ=0.74±0.1), and were slightly improved with the dichotomized score (from κ=0.19±0.2 to κ=0.79±0.11).
Inter- and intraobserver agreement of collateral circulation grading using the ASITN/SIR score was poor, raising concerns about comparisons among publications. A simplified dichotomized judgment may be a more reproducible assessment when images are rated by the same observer(s) in randomized trials.
Several studies have investigated the histopathology of mechanically retrieved thrombi from stroke patients. Thrombi with unusual components constitute about 1-2% of all stroke thrombi in clinical ...practice. Knowledge about these rare components is limited.
To characterize the histopathology of unusual stroke thrombi from a real-world setting with relation to clinical presentation, patient characteristics and procedural aspects of mechanical thrombectomy.
One-thousand and eight thrombi retrieved from stroke patients with mechanical thrombectomy at three different hospitals were retrospectively reviewed for unusual histological components. Fifteen thrombi were included in the study for further histopathological analysis. Clinical data and data on procedural aspects were collected.
We identified six cases with large amounts of extracellular DNA, of which three were calcified. All six cases except one received anticoagulant therapy. We describe two types of calcifications that differ with respect to general calcification morphology, von Kossa staining pattern, macrophage immunophenotype and presence of multinucleated giant cells. Cholesterol-rich (
= 3), adipocyte-like pattern-rich (
= 2), collagen-rich (
= 2) and myxomatous (
= 1) thrombi were also identified and are discussed with regard to pathogenesis and clinical and intervention characteristics. Finally, a thrombus with parts of a vascular wall is described. Suggestions for future studies are made and clinical and technical aspects of the management for these rare but important patients are discussed.
In our retrospective multicenter study, we characterized stroke thrombi histopathologically and found subgroups of thrombi defined by presence of rarely seen components. These defined subgroups showed relation to underlying cardiovascular disease, patient characteristics, and mechanical thrombectomy technique. Knowledge about these components may increase our understanding of stroke pathophysiology and influence interventional procedures.
Reduced exercise capacity severely impacts quality of life in pulmonary Langerhans cell histiocytosis. Ascertaining mechanisms that impair exercise capacity is necessary to identify targets for ...symptomatic treatments.
Dyspnea, pulmonary function tests and cardiopulmonary exercise test were analysed in 62 study participants. Data were compared between subjects with impaired and normal aerobic capacity (V'O2 peak less than 84% versus 84% predicted or more). Data were reduced using a principal component analysis. Multivariate analysis included V'O2 peak as the dependent variable and principal components as covariates.
V'O2 peak was reduced in 44 subjects (71%). Subjects with impaired aerobic capacity presented: (i) decreased FEV1, FVC, FEV1/FVC, DLCO and DLCO/VA and increased AaDO2, (ii) increased ventilatory equivalents at ventilatory threshold, VD/VT peak, AaDO2 peak and PaCO2 peak and decreased ventilatory reserve and PaO2 peak. There was no difference between groups in dyspnea scores. Principal component analysis extracted 4 principal components interpreted as follows: PC1: gas exchange; PC2: "pseudorestriction"; PC3: exercise-induced hyperpnea; PC4: air trapping. Multivariate analysis explained 65% of V'O2 peak. The 4 principal components were independently associated with V'O2 peak (βcoefficients: PC1: 9.3 4.6; 14, PC2: 7.5 3; 11.9, PC3: -5.3 -9.6;-1., PC4: -9.8 -14,9;-4.7).
Impaired exercise capacity is frequent in pulmonary Langerhans cell histiocytosis. It is mainly caused by pulmonary changes but is not associated with increased dyspnea intensity. Therefore, treating the lung represents a relevant approach for improving exercise capacity, even in patients experiencing mild dyspnea.
To study the safety and performance of real-world thrombectomy using the SOFIA Catheter in our comprehensive stroke center.
We conducted a cohort study from a prospective clinical registry of ...consecutive stroke patients treated by mechanical thrombectomy between March 2016 and September 2017. Baseline clinical and imaging characteristics, recanalization rates, complications, and clinical outcomes were analyzed.
Among the 140 patients included, 54 were treated using aspiration first, 64 were treated using aspiration and stent-retriever straightaway, and 22 were treated with SOFIA as a rescue device. Successful recanalization (Modified Thrombolysis In Cerebral Infarction score 2b/3) was achieved in 82.1% patients and good outcomes in 34.3%. Symptomatic intracranial hemorrhage occurred in 7.1% and mortality in 25%.
In our single-center experience, thrombectomy using the SOFIA as an intermediate or aspiration catheter provided high recanalization rates under everyday conditions.
The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate ...estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale mRS 3–6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3–6 at 90 days was 74% (99% confidence interval CI, 67 to 84; Z-value=7.04; I2=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=–7.07; I2=74.5). Receiving MT was associated with a significant decrease in mRS 3–6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=–5.92; I2=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=–2.30; I2=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=–0.63; I2=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.
Background and Purpose Acute stroke in the setting of acute type A aortic dissection is not rare and may contraindicate immediate surgery. Evaluating irreversible brain damage is critical in this ...setting and magnetic resonance imaging is a key determinant in the decision of selecting surgical over medical treatment for these patients. Summary of Cases We report herein 2 cases assessed at a tertiary care center for acute stroke. The initial diagnosis workup revealed cerebral hemispheric severe hypoperfusion without any brain infarction. The absence of ischemic lesions prompted surgical repair, despite the severity of clinical symptoms. Both patients demonstrated complete neurological recovery and neuroimaging showed no persistent sequel. Conclusion Acute type A aortic dissection is an important differential diagnosis in the causative workup for stroke. Brain hypoperfusion alone should not be a contraindication for urgent surgical treatment, regardless of initial clinical neurological severity.
Background and Purpose:
Despite initial successful recanalization after mechanical thrombectomy (MT), some patients with large artery occlusion (LAO)-related stroke will experience an early ...reocclusion of the injured vessel which may worsen their prognosis. We aimed to investigate the prevalence, associated factors and prognosis of early reocclusion after successful MT in a large prospective cohort of stroke patients with LAO.
Methods:
We included patients from the Lille reperfusion registry with LAO-related stroke involving M1 segment, internal carotid artery terminus or tandem ICA-M1 occlusion, with successful recanalization after MT and available 24 h imaging follow-up. Early reocclusion was defined as internal carotid artery terminus or M1 occlusion on 24 h magnetic resonance imaging (MRI) or computed tomography (CT) vascular imaging. Multivariable logistic regression models were used to investigate factors associated with early reocclusion and its impact on outcomes.
Results:
Between 2015 and 2020, 62 of 1015 included patients experienced an early reocclusion (6.1%). Age (odds ratio (OR) per 15 years decrease: 1.38 (1.05–1.81)) antiplatelet use (OR: 0.41 (0.19–0.89)), several device passes (OR: 2.13 (1.18–3.83)), atherosclerosis cause (OR: 2.38 (1.19–4.78)), and early clinical worsening (OR: 2.45 (1.18–5.07)) were independently associated with early reocclusion. Early reocclusion was independently associated with poor prognosis (OR: 7.15 (3.49–14.65)) and mortality (OR: 2.05 (1.07–3.91)) at 3 months.
Conclusion:
Six percent of patients with LAO-related stroke and initial successful recanalization experienced early reocclusion. This event is associated with a 7-fold increased risk of poor functional outcome and a 2-fold increased risk of mortality. Further efforts are warranted to refine early detection of patients at risk of reocclusion and to improve their management.
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