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1. Tissue outcome prediction in hyperacute ischemic stroke: Comparison of machine learning models

Author

Sylvain Charron, Guillaume Turc, Jean-Claude Baron, Joseph Benzakoun, Bertrand Thirion, Wagih Ben Hassen, Gregoire Boulouis, Catherine Oppenheim, Olivier Naggara, Laurence Legrand, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), GHU Paris Psychiatrie et Neurosciences, Université de Paris - UFR Médecine Paris Centre [Santé] (UP Médecine Paris Centre), Université de Paris (UP), Modelling brain structure, function and variability based on high-field MRI data (PARIETAL), Inria Saclay - Ile de France, Institut National de Recherche en Informatique et en Automatique (Inria)-Institut National de Recherche en Informatique et en Automatique (Inria)-Service NEUROSPIN (NEUROSPIN), Université Paris-Saclay-Direction de Recherche Fondamentale (CEA) (DRF (CEA)), Commissariat à l'énergie atomique et aux énergies alternatives (CEA)-Commissariat à l'énergie atomique et aux énergies alternatives (CEA)-Université Paris-Saclay-Direction de Recherche Fondamentale (CEA) (DRF (CEA)), Commissariat à l'énergie atomique et aux énergies alternatives (CEA)-Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), UFR Médecine [Santé] - Université Paris Cité (UFR Médecine UPCité), Université Paris Cité (UPCité), Service NEUROSPIN (NEUROSPIN), Commissariat à l'énergie atomique et aux énergies alternatives (CEA)-Commissariat à l'énergie atomique et aux énergies alternatives (CEA)-Inria Saclay - Ile de France, and Institut National de Recherche en Informatique et en Automatique (Inria)-Institut National de Recherche en Informatique et en Automatique (Inria)

Subjects
Male, Clinical Decision-Making, 030204 cardiovascular system & hematology, Machine learning, computer.software_genre, Machine Learning, 03 medical and health sciences, 0302 clinical medicine, Predictive Value of Tests, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Humans, Medicine, Acute ischemic stroke, Stroke, Aged, Ischemic Stroke, Retrospective Studies, Neuroradiology, Aged, 80 and over, business.industry, Penumbra, Brain, Original Articles, Middle Aged, Prognosis, medicine.disease, Patient management, Diffusion Magnetic Resonance Imaging, Neurology, Infarction, Reperfusion, Ischemic stroke, Female, Neurology (clinical), Artificial intelligence, Treatment decision making, Cardiology and Cardiovascular Medicine, Outcome prediction, business, computer, 030217 neurology & neurosurgery, Follow-Up Studies
Abstract

Machine Learning (ML) has been proposed for tissue fate prediction after acute ischemic stroke (AIS), with the aim to help treatment decision and patient management. We compared three different ML models to the clinical method based on diffusion-perfusion thresholding for the voxel-based prediction of final infarct, using a large MRI dataset obtained in a cohort of AIS patients prior to recanalization treatment. Baseline MRI (MRI0), including diffusion-weighted sequence (DWI) and Tmax maps from perfusion-weighted sequence, and 24-hr follow-up MRI (MRI24h) were retrospectively collected in consecutive 394 patients AIS patients (median age = 70 years; final infarct volume = 28mL). Manually segmented DWI24h lesion was considered the final infarct. Gradient Boosting, Random Forests and U-Net were trained using DWI, apparent diffusion coefficient (ADC) and Tmax maps on MRI0 as inputs to predict final infarct. Tissue outcome predictions were compared to final infarct using Dice score. Gradient Boosting had significantly better predictive performance (median [IQR] Dice Score as for median age, maybe you can replace the comma with an equal sign for consistency 0.53 [0.29–0.68]) than U-Net (0.48 [0.18–0.68]), Random Forests (0.51 [0.27–0.66]), and clinical thresholding method (0.45 [0.25–0.62]) ( P

Published
2021
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2. Impact of Repeated Clot Retrieval Attempts on Infarct Growth and Outcome After Ischemic Stroke

Author

Olivier Naggara, Martin Bretzner, Nicolas Bricout, Guillaume Turc, C Rodriguez, Laurence Legrand, Pierre Seners, Alice Le Berre, Joseph Benzakoun, Charlotte Cordonnier, Caroline Touloupas, Hilde Hénon, Wagih Ben Hassen, Gregoire Boulouis, and Catherine Oppenheim

Subjects
Male, medicine.medical_specialty, medicine.medical_treatment, Arterial Occlusive Diseases, 030204 cardiovascular system & hematology, Neurosurgical Procedures, 03 medical and health sciences, 0302 clinical medicine, Meta-Analysis as Topic, Risk Factors, Modified Rankin Scale, Internal medicine, medicine, Humans, Thrombolytic Therapy, Binary logistic regression analysis, Prospective Studies, Aged, Ischemic Stroke, Thrombectomy, Aged, 80 and over, Cerebral infarction, business.industry, Cerebral Infarction, Thrombolysis, Odds ratio, Middle Aged, medicine.disease, Confidence interval, Mechanical thrombectomy, Diffusion Magnetic Resonance Imaging, Treatment Outcome, Ischemic stroke, Cardiology, Female, Neurology (clinical), business, 030217 neurology & neurosurgery
Abstract

ObjectiveTo determine whether the association between increasing number of clot retrieval attempts (CRA) and unfavorable outcome is due to an increase in emboli to new territory (ENT) and greater infarct growth (IG) in successfully recanalized patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO).MethodsData were extracted from 2 pooled multicentric prospective registries of consecutive patients with anterior AIS-LVO treated with mechanical thrombectomy (MT) between January 2016 and 2019. Patients with pretreatment and 24-hour posttreatment diffusion-weighted imaging (DWI) achieving successful recanalization, defined as expanded Thrombolysis in Cerebral Infarction Scale score of 2B, 2C, or 3, were included. ENT were assessed and IG was measured by voxel-based segmentation after DWI coregistration. Associations between number of CRA, ENT, IG, and 3-month outcome were analyzed.ResultsFour hundred nineteen patients achieving successful recanalization were included. ENT occurrence was strongly correlated with increasing CRA (ρ = 0.73, p = 10−4). In multivariable linear analysis, IG was independently associated with CRA (β = 1.6 per retrieval attempt, 95% confidence interval [CI] 0.97–9.74, p = 0.03) and ENT (β = 2.7 [95% CI 1.21–4.1], p = 0.03). Unfavorable functional outcome (3-month modified Rankin Scale score >2) increased with each additional CRA. IG was an independent predictor of unfavorable outcome (odds ratio 1.05 [95% CI 1.02–1.07] per 1-mL IG increase, p = 10−4) in binary logistic regression analysis.ConclusionsIncreasing number of CRA in acute stroke is correlated with an increased ENT rate and increased IG volume, affecting functional outcome even when successful recanalization is achieved.Classification of EvidenceThis study provides Class II evidence that, for patients with acute stroke undergoing successful recanalization, an increasing number of CRA is associated with poorer functional outcome.

Published
2021
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3. First-line thrombectomy strategy for anterior large vessel occlusions: results of the prospective ETIS egistry

Author

Benjamin, Maïer, Stephanos, Finitsis, Romain, Bourcier, Panagiotis, Papanagiotou, Sébastien, Richard, Gaultier, Marnat, Igor, Sibon, Cyril, Dargazanli, Caroline, Arquizan, Raphael, Blanc, Michel, Piotin, Bertrand, Lapergue, Arturo, Consoli, Francois, Eugene, Stephane, Vannier, Suzana, Saleme, Francisco, Macian, Frédéric, Clarençon, Charlotte, Rosso, Olivier, Naggara, Guillaume, Turc, Alain, Viguier, Christophe, Cognard, Valerie, Wolff, Raoul, Pop, Mikael, Mazighi, Benjamin, Gory, Thomas, Ronziere, Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), UFR Médecine [Santé] - Université Paris Cité (UFR Médecine UPCité), Université Paris Cité (UPCité), Aristotle University of Thessaloniki, Centre hospitalier universitaire de Nantes (CHU Nantes), Klinikum Bremen-Mitte, National and Kapodistrian University of Athens (NKUA), Service de neurologie [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Département de Neuro-Radiologie [Bordeaux] (DNR - Bordeaux), CHU Bordeaux [Bordeaux], Service de neurologie [Bordeaux], CHU Bordeaux [Bordeaux]-Groupe hospitalier Pellegrin, Département de Neuroradiologie[Montpellier], Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Gui de Chauliac [Montpellier]-Université de Montpellier (UM), Département de neurologie [Montpellier], Service Neuroradiologie diagnostique et interventionnelle [Hôpital Foch], Hôpital Foch [Suresnes], Département de Radiologie [Rennes], Université de Rennes (UR), Service de Neurologie [Rennes] = Neurology [Rennes], CHU Pontchaillou [Rennes], Service de Neuroradiologie interventionnelle [CHU Limoges], CHU Limoges, Service de Neurologie [CHU Limoges], Service de Neuroradiologie [CHU Pitié-Salpêtrière], CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Université Sorbonne Paris Nord, Service d'Urgences Cérébro-Vasculaires [CHU Pitié-Salpêtrière], Service de Neurologie [CH Saint-Anne], Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Neurologie Vasculaire [Toulouse], Centre Hospitalier Universitaire de Toulouse (CHU Toulouse), Pôle Neurosciences [CHU Toulouse], Service de Neurologie [Strasbourg], CHU Strasbourg-Hopital Civil, Département de Neuroradiologie [Strasbourg], Les Hôpitaux Universitaires de Strasbourg (HUS), Institut de Chirurgie guidée par l'Image, and Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy]

Subjects
medicine.medical_specialty, MESH: Endovascular Procedures, medicine.medical_treatment, Arterial Occlusive Diseases, MESH: Stroke, Brain Ischemia, law.invention, Randomized controlled trial, Modified Rankin Scale, law, medicine.artery, Internal medicine, Stent, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, medicine, Humans, Device, MESH: Thrombectomy, Prospective Studies, Stroke, Ischemic Stroke, Retrospective Studies, Thrombectomy, MESH: Treatment Outcome, Catheter, MESH: Arterial Occlusive Diseases, MESH: Humans, Cerebral infarction, business.industry, [SCCO.NEUR]Cognitive science/Neuroscience, Endovascular Procedures, MESH: Brain Ischemia, MESH: Retrospective Studies, General Medicine, Thrombolysis, medicine.disease, MESH: Prospective Studies, MESH: Stents, Treatment Outcome, Cardiology, Stents, Surgery, Neurology (clinical), Internal carotid artery, business, MESH: Ischemic Stroke
Abstract

BackgroundThe best recanalization strategy for mechanical thrombectomy (MT) remains unknown as no randomized controlled trial has simultaneously evaluated first-line stent retriever (SR) versus contact aspiration (CA) versus the combined approach (SR+CA).ObjectiveTo compare the efficacy and safety profiles of SR, CA, and SR+CA in patients with acute ischemic stroke (AIS) treated by MT.MethodsWe analyzed data of the Endovascular Treatment in Ischemic Stroke (ETIS) Registry, a prospective, multicenter, observational study of patients with AIS treated by MT. Patients with M1 and intracranial internal carotid artery (ICA) occlusions between January 2015 and March 2020 in 15 comprehensive stroke centers were included. We assessed the association of first-line strategy with favorable outcomes at 3 months (modified Rankin Scale score 0–2), successful recanalization rates (modified Thrombolysis In Cerebral Infarction (mTICI) 2b/3), and safety outcomes.ResultsWe included 2643 patients, 406 treated with SR, 1126 with CA, and 1111 with SR+CA. CA or SR+CA achieved more successful recanalization than SR for M1 occlusions (aOR=2.09, (95% CI 1.39 to 3.13) and aOR=1.69 (95% CI 1.12 to 2.53), respectively). For intracranial ICA, SR+CA achieved more recanalization than SR (aOR=2.52 (95% CI 1.32 to 4.81)), no differences were observed between CA and SR+CA. SR+CA was associated with lower odds of favorable outcomes compared with SR (aOR=0.63 (95% CI 0.44 to 0.90)) and CA (aOR=0.71 (95% CI 0.55 to 0.92)), higher odds of mortality at 3 months (aOR=1.56 (95% CI 1.22 to 2.0)) compared with CA, and higher odds of symptomatic intracranial hemorrhage (aOR=1.59 (95% CI 1.1 to 2.3)) compared with CA.ConclusionsDespite high recanalization rates, our results question the safety of the combined approach, which was associated with disability and mortality. Randomized controlled trials are needed to evaluate the efficacy and safety of these techniques.

Published
2021
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4. Maintenance of Acute Stroke Care Service During the COVID-19 Pandemic Lockdown

Author

Alessandro Pezzini, Valerian L Altersberger, Bruno Gonçalves, Jan F. Scheitz, Andreas Kastrup, Annika Nordanstig, Alessandro Padovani, Patrik Michel, Christian H. Nolte, Susanne Wegener, Marcel Arnold, Andrea Zini, Christian Hametner, Marialuisa Zedde, Peter A. Ringleb, Paul J. Nederkoorn, Ronen R. Leker, Henrik Gensicke, Georges Ntaios, Guillaume Turc, Lotte J. Stolze, Leon A. Rinkel, Stefania Nannoni, Nicolas Martinez-Majander, Georg Kägi, Leo H. Bonati, Alexandros Rentzos, Stefan T. Engelter, Charlotte Cordonnier, Carlo W. Cereda, Sami Curtze, Mauro Gentile, Hilde Hénon, Philipp Baumgartner, Visnja Padjen, Mirjam Rachel Heldner, Urs Fischer, Panagiotis Papanagiotou, GHU Paris Psychiatrie et Neurosciences, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Graduate School, Neurology, ACS - Atherosclerosis & ischemic syndromes, and ANS - Neurovascular Disorders

Subjects
Male, medicine.medical_treatment, [SDV]Life Sciences [q-bio], Original Contributions, 030204 cardiovascular system & hematology, Severity of Illness Index, Cohort Studies, 0302 clinical medicine, quality of care, Epidemiology, Pandemic, Medicine, Thrombolytic Therapy, Registries, Stroke, Aged, 80 and over, Thrombolysis, Middle Aged, 3. Good health, reperfusion, Europe, Hospitalization, Treatment Outcome, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Female, Cardiology and Cardiovascular Medicine, Cohort study, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Critical Care, Physical Distancing, Cardiology, Time-to-Treatment, 03 medical and health sciences, Clinical and Population Sciences, Reperfusion therapy, Severity of illness, ischemic stroke, Humans, Pandemics, Aged, Advanced and Specialized Nursing, business.industry, COVID-19, medicine.disease, Emergency medicine, Neurology (clinical), business, 030217 neurology & neurosurgery, intracranial hemorrhage
Abstract

Supplemental Digital Content is available in the text., Background and Purpose: Timely reperfusion is an important goal in treatment of eligible patients with acute ischemic stroke. However, during the coronavirus disease 2019 (COVID-19) pandemic, prehospital and in-hospital emergency procedures faced unprecedented challenges, which might have caused a decline in the number of acute reperfusion therapy applied and led to a worsening of key quality measures for this treatment during lockdown. Methods: This prospective multicenter cohort study used data from the TRISP (Thrombolysis in Ischemic Stroke Patients) registry of patients with acute ischemic stroke treated with reperfusion therapies, that is, intravenous thrombolysis or endovascular therapy. We compared prehospital and in-hospital time-based performance measures (stroke-onset-to-admission, admission-to-treatment, admission-to-image, and image-to-treatment time) during the first 6 weeks after announcement of lockdown (lockdown period) with the same period in 2019 (reference period). Secondary outcomes included stroke severity (National Institutes of Health Stroke Scale) after 24 hours and occurrence of symptomatic intracranial hemorrhage (following the ECASS [European-Australasian Acute Stroke Study]-II criteria). Results: Across 20 stroke centers, 540 patients were treated with intravenous thrombolysis/endovascular therapy during lockdown period compared with 578 patients during reference period (−7% [95% CI, 5%–9%]). Performance measures did not change significantly during the lockdown period (2020/2019 minutes median: onset-to-admission 133/145; admission-to-treatment 51/48). Same was true for admission-to-image (20/19) and image-to-treatment (31/30) time in patients with available time of first image (n=871, 77.9%). Median National Institutes of Health Stroke Scale on admission (2020/2019: 11/11) and after 24 hours (2020/2019: 6/5) and percentage of symptomatic intracranial hemorrhage (2020/2019: 6.2/5.7) did not differ significantly between both periods. Conclusions: The COVID-19 pandemic lockdown resulted in a mild decline in the number of patients with stroke treated with acute reperfusion therapies. More importantly, the solid stability of key quality performance measures between the 2020 and 2019 period may indicate resilience of acute stroke care service during the lockdown, at least in well-established European stroke centers.

Published
2021
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5. Author Reply to 'Intravenous thrombolysis in patients taking direct oral anticoagulants (European stroke organisation intravenous thrombolysis guidelines comment)

Author

Guillaume Turc, Gian Marco De Marchis, William Whiteley, and Georgios Tsivgoulis

Subjects
medicine.medical_specialty, business.industry, medicine.medical_treatment, Emergency medicine, medicine, In patient, Neurology (clinical), Thrombolysis, Letters to the Editor, Cardiology and Cardiovascular Medicine, medicine.disease, business, Stroke
Published
2021
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6. Clinical Outcome of Acute Ischemic Strokes in Patients with COVID-19

Author

Michael Obadia, Thomas De Broucker, Mikael Mazighi, David Varlan, Aïcha Lyoubi, Julie Calmettes, Bruno Gonçalves, Guillaume Turc, E. Meppiel, Roxane Peres, and Clotilde Nardin

Subjects
Male, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Acute ischemic stroke, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, Internal medicine, Diabetes Mellitus, medicine, Humans, In patient, Hospital Mortality, Obesity, Clinical Research in Stroke, Aged, Ischemic Stroke, Retrospective Studies, Outcome, Aged, 80 and over, SARS-CoV-2, business.industry, Medical record, Mortality rate, Case-control study, COVID-19, Retrospective cohort study, Middle Aged, Prognosis, medicine.disease, Functional Status, Neurology, Case-Control Studies, Female, Observational study, France, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery
Abstract

Introduction: Acute ischemic stroke (AIS) and thrombotic events (TEs) were reported in patients with COVID-19. Clinical outcome of AIS in the course of COVID-19 remains unknown. We compared early clinical outcome and mortality of COVID-positive (+) patients admitted for AIS with COVID-negative (−) ones. We hypothesized that COVID+ patients would have poorer clinical outcomes and present a higher rate of TEs and mortality compared with COVID− ones. Methods: In this multicentric observational retrospective study, we enrolled patients over 18 years old admitted for AIS in 3 stroke units of the Parisian region during lockdown from March 17, 2020, to May 2, 2020. COVID-19 status as well as demographic, clinical, biological, and imaging data was collected retrospectively from medical records. Poor outcome was defined as modified Rankin score (mRS) 3–6 (3–6) at discharge. We also compared TE frequency and mortality rate through a composite criterion in both groups. Results: Two hundred and sixteen patients were enrolled; mean age was 68 years old, and 63% were male. Forty patients were CO­VID+ (18.5%) and 176 were COVID−. Obesity was statistically more frequent in the COVID+ group (36 vs. 13% p < 0.01). The percentage of patients with mRS (3–6) at discharge was higher in the COVID+ group compared with the COVID− group (60 vs. 41%, p = 0.034). The main predictor of presenting a mRS (3–6) at discharge was high NIHSS score at admission (OR, CI 95%: 1.325, 1.22–1.43). Mortality rate was higher in the COVID+ group (12 vs. 3.4%, p = 0.033) as well as TE frequency (15 vs. 2.8%, p < 0.01). Conclusion: In this study, patients with AIS infected by SARS-CoV-2 showed a poorer early outcome than COVID− ones. However, when compared to other factors, COVID-19 was not a significant predictor of poor outcome. Vascular morbidity and mortality rates were significantly higher in the COVID+ group compared with the COVID− group.

Published
2021
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7. Association of prestroke metformin use, stroke severity, and thrombolysis outcome

Author

Sixtine Gilliot, Hebun Erdur, Christian H. Nolte, Paul J. Nederkoorn, Mauro Magoni, Christian Hametner, Andrea Zini, Patrik Michel, Pierre Seners, Michael J Scherrer, Laura P. Westphal, Ashraf Eskandari, Jonathan M. Coutinho, Sami Curtze, Yannick Béjot, Nicolas Martinez-Majander, Céline Brenière, Georg Kägi, Adrien E. Groot, Didier Leys, Alexandros A Polymeris, Laura Vandelli, Ulrike Held, Alessandro Pezzini, Stefan T. Engelter, Andreas R. Luft, Jan F. Scheitz, Marcel Arnold, Marjaana Tiainen, Roni Widmer, Klaus Steigmiller, Susanne Wegener, Peter A. Ringleb, Christopher Traenka, Mirjam Rachel Heldner, Visnja Padjen, Dejana R. Jovanović, Turgut Tatlisumak, Guillaume Turc, Henrik Gensicke, University of Zurich, Neurology, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, Graduate School, and ACS - Amsterdam Cardiovascular Sciences

Subjects
Male, medicine.medical_specialty, medicine.medical_treatment, 610 Medicine & health, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Modified Rankin Scale, Internal medicine, Diabetes mellitus, Epidemiology, medicine, Humans, Hypoglycemic Agents, Thrombolytic Therapy, cardiovascular diseases, 10064 Neuroscience Center Zurich, Stroke, Aged, Retrospective Studies, business.industry, Recovery of Function, 10060 Epidemiology, Biostatistics and Prevention Institute (EBPI), Thrombolysis, Middle Aged, medicine.disease, Metformin, 10040 Clinic for Neurology, 3. Good health, 2728 Neurology (clinical), Diabetes Mellitus, Type 2, Propensity score matching, Cohort, Female, Neurology (clinical), business, 030217 neurology & neurosurgery, medicine.drug
Abstract

ObjectiveTo evaluate whether pretreatment with metformin (MET) is associated with less stroke severity and better outcome after IV thrombolysis (IVT), we analyzed a cohort of 1,919 patients with stroke with type 2 diabetes mellitus in a multicenter exploratory analysis.MethodsData from patients with diabetes and ischemic stroke treated with IVT were collected within the European Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration. We applied propensity score matching (PSM) to obtain balanced baseline characteristics of patients treated with and without MET.ResultsOf 1,919 patients with stroke with type 2 diabetes who underwent IVT, 757 (39%) had received MET before stroke (MET+), whereas 1,162 (61%) had not (MET−). MET+ patients were younger with a male preponderance. Hypercholesterolemia and pretreatment with statins, antiplatelets, or antihypertensives were more common in the MET+ group. After PSM, the 2 groups were well balanced with respect to demographic and clinical aspects. Stroke severity on admission (NIH Stroke Scale 10.0 ± 6.7 vs 11.3 ± 6.5), 3-month degree of independence on modified Rankin Scale (2 [interquartile range (IQR) 1.0–4.0] vs 3 [IQR 1.0–4.0]), as well as mortality (12.5% vs 18%) were significantly lower in the MET+ group. The frequency of symptomatic intracerebral hemorrhages did not differ between groups. HbA1c levels were well-balanced between the groups.ConclusionsPatients with stroke and diabetes on treatment with MET receiving IVT had less severe strokes on admission and a better functional outcome at 3 months. This suggests a protective effect of MET resulting in less severe strokes as well as beneficial thrombolysis outcome.

Published
2020
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8. Absence of fear of dying predicts new organ failure: Results of a multicenter prospective observational cohort study

Author

Raphaël Porcher, Aurélien Mazeraud, Marion Antona, Cassia Righy, S Sivanandamoorthy, Fernando Bozza, Tarek Sharshar, Annabelle Stoclin, Andrea Polito, Shidasp Siami, and Guillaume Turc

Subjects
Pediatrics, medicine.medical_specialty, business.industry, medicine, business, Cohort study
Abstract

Rationale: Intensity of anxiety at admission in intensive care unit (ICU) is associated with subsequent deterioration.Objective: The primary aim of this study was to assess predictive value of stressful fears and feelings to predict new organ failure within the first seven days after ICU admission.Methods: We conducted a prospective three-center cohort study of non-comatose patients without delirium or invasive mechanical ventilation. A twelve-item questionnaire was developed to assess stressful fears and feelings. Illness severity was assessed using SAPS-II and SOFA scores. Intensity of chronic and acute anxiety was assessed with the ‘Trait’ and ‘State’ forms of the State-Trait Anxiety Inventory (STAI). Patients were followed-up for seven days. Results: From April 2014 to December 2017, 373 patients (median age, 63y.o. [49-74]; 159 [40.7%] women; SAPS-II 28 [19-37]) were included. Feeling of vulnerability and fear of dying was reported in 209 (54.4%) and 178 (46.4%) patients, respectively. STAI was equal or above 40 in 192 (51.5%) patients. Ninety-four (25.2%) patients developed a new organ failure. Feeling of vulnerability (OR=1.96, 95%CI:1.12-3.43], p=0.01) and absence of fear of dying (OR=2.38, 95%CI:1.37-4.17], p=0.002) were associated with occurrence of a new organ failure after adjustment on STAI ≥40, SAPS-II and SOFA. Conclusion: Absence of fear of dying is associated with occurrence of new organ failure within the seven post-ICU admission days. We hypothesize that fear of dying might be protective for subsequent deterioration by mobilizing patient’s homeostatic resources. Trial registration: NCT02355626

Published
2021
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9. Functional Outcome, Recanalization, and Hemorrhage Rates After Large Vessel Occlusion Stroke Treated With Tenecteplase Before Thrombectomy

Author

Gaspard, Gerschenfeld, Didier, Smadja, Guillaume, Turc, Stephane, Olindo, François-Xavier, Laborne, Marion, Yger, Jildaz, Caroff, Bruno, Gonçalves, Pierre, Seners, Marie, Cantier, Yann, l'Hermitte, Manvel, Aghasaryan, Cosmin, Alecu, Gaultier, Marnat, Wagih, Ben Hassen, Erwah, Kalsoum, Frédéric, Clarençon, Michel, Piotin, Laurent, Spelle, Christian, Denier, Igor, Sibon, Sonia, Alamowitch, Nicolas, Chausson, Mikael, Mazighi, Service de Neurologie [CHU Saint-Antoine], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-CHU Saint-Antoine [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Sorbonne Université (SU), Sorbonne Université - Faculté de Médecine (SU FM), Sorbonne Université (SU), Service de Neurologie et Unité Neurovasculaire [Centre Hospitalier Sud-Francilien], Université Paris-Sud - Paris 11 (UP11)-Centre Hospitalier Sud Francilien, CH Evry-Corbeil-CH Evry-Corbeil, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), GHU Paris Psychiatrie et Neurosciences, FHU NeuroVasc [Site Sainte-Anne, Paris] (GHU-PPN), Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université de Paris (UP), Service de neurologie [Bordeaux], CHU Bordeaux [Bordeaux]-Groupe hospitalier Pellegrin, Centre Hospitalier Sud Francilien, CH Evry-Corbeil, AP-HP Hôpital Bicêtre (Le Kremlin-Bicêtre), Service de Neurologie, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU Neurovasc, Paris, France, CHU Bordeaux [Bordeaux], CHU Henri Mondor, CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], TETRIS study group, Martinez Rico, Clara, CHU Saint-Antoine [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Cité (UPCité), and Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)

Subjects
Male, Tenecteplase, 030204 cardiovascular system & hematology, Brain Ischemia, Ischemia score, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Modified Rankin Scale, Interquartile range, medicine, Humans, Thrombolytic Therapy, In patient, [SDV.NEU] Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Stroke, Aged, Cerebral Hemorrhage, Ischemic Stroke, Retrospective Studies, Thrombectomy, Aged, 80 and over, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, medicine.diagnostic_test, business.industry, Middle Aged, medicine.disease, 3. Good health, Treatment Outcome, Anesthesia, Angiography, Female, [SDV.NEU]Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Neurology (clinical), business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, Large vessel occlusion, medicine.drug
Abstract

Background and ObjectivesTo investigate in routine care the efficacy and safety of IV thrombolysis (IVT) with tenecteplase prior to mechanical thrombectomy (MT) in patients with large vessel occlusion acute ischemic strokes (LVO-AIS), either secondarily transferred after IVT or directly admitted to a comprehensive stroke center (CSC).MethodsWe retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent brain angiography. The main outcome was 3-month functional independence (modified Rankin Scale score ≤2). Recanalization (revised Treatment in Cerebral Ischemia score 2b–3) was evaluated before (pre-MT) and after MT (final).ResultsWe included 588 patients (median age 75 years [interquartile range (IQR) 61–84]; 315 women [54%]; median NIH Stroke Scale score 16 [IQR 10–20]), of whom 520 (88%) were secondarily transferred after IVT. Functional independence occurred in 47% (n = 269/570; 95% confidence interval [CI] 43.0–51.4) of patients. Pre-MT recanalization occurred in 120 patients (20.4%; 95% CI 17.2–23.9), at a similar rate across treatment paradigms (direct admission, n = 14/68 [20.6%]; secondary transfer, n = 106/520 [20.4%]; p > 0.99) despite a shorter median IVT to puncture time in directly admitted patients (38 [IQR 23–55] vs 86 [IQR 70–110] minutes; p < 0.001). Final recanalization was achieved in 492 patients (83.7%; 95%CI 80.4–86.6). Symptomatic intracerebral hemorrhage occurred in 2.5% of patients (n = 14/567; 95% CI 1.4–4.1).DiscussionsTenecteplase before MT is safe, effective, and achieves a fast recanalization in everyday practice in patients secondarily transferred or directly admitted to a CSC, in line with published results. These findings should encourage its wider use in bridging therapy.Classification of EvidenceThis study provides Class IV evidence that tenecteplase within 270 minutes of LVO-AIS increases the probability of functional independence.

Published
2021
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10. Impact of Prior Antiplatelet Therapy on Outcomes After Endovascular Therapy for Acute Stroke: Endovascular Treatment in Ischemic Stroke Registry Results

Author

Marie Couture, Stephanos Finitsis, Gaultier Marnat, Sébastien Richard, Romain Bourcier, Pacôme Constant-dits-Beaufils, Cyril Dargazanli, Caroline Arquizan, Mikaël Mazighi, Raphaël Blanc, François Eugène, Stéphane Vannier, Laurent Spelle, Christian Denier, Emmanuel Touzé, Charlotte Barbier, Suzana Saleme, Francisco Macian, Charlotte Rosso, Frédéric Clarençon, Olivier Naggara, Guillaume Turc, Ozlem Ozkul-Wermester, Chrysanthi Papagiannaki, Alain Viguier, Christophe Cognard, Anthony Lebras, Sarah Evain, Valérie Wolff, Raoul Pop, Serge Timsit, Jean-Christophe Gentric, Frédéric Bourdain, Louis Veunac, Bertrand Lapergue, Arturo Consoli, Benjamin Gory, Igor Sibon, Michel Piotin, Hocine Redjem, Simon Escalard, Jean-Philippe Dessilles, François Delvoye, Stanislas Smajda, Benjamin Maier, Hebert Solène, Mikael Obadia, Candice Sabben, Pierre Seners, Igor Raynouard, Ovide Corabianu, Thomas de Broucker, Eric Manchon, Guillaume Taylor, Malek Ben Maacha, Laurie-Anne Thion, Augustin Lecler, Julien Savatovsjy, Adrien Wang, Serge Evrard, Maya Tchikviladze, Nadia Ajili, David WeisenburgerLile, Lucas Gorza, Géraldine Buard, Oguzhan Coskun, Federico Di Maria, Georges Rodesh, Sergio Zimatore, Morgan Leguen, Julie Gratieux, Fernando Pico, Haja Rakotoharinandrasana, Philippe Tassan, Roxanna Poll, Sylvie Marinier, Florent Gariel, Xavier Barreau, Jérôme Berge, Patrice Menegon, Ludovic Lucas, Stéphane Olindo, Pauline Renou, Sharmila Sagnier, Mathilde Poli, Sabrina Debruxelles, François Rouanet, Thomas Tourdias, Jean-Sebastien Liegey, Pierre Briau, Nicolas Pangon, Lili Detraz, Benjamin Daumas-Duport, Pierre-Louis Alexandre, Monica Roy, Cédric Lenoble, Hubert Desal, Benoît Guillon, Solène de Gaalon, Cécile Preterre, Serge Bracard, René Anxionnat, Marc Braun, Anne-Laure Derelle, Liang Liao, Romain Tonnelet, François Liao, Emmanuelle Zhu, Sophie Schmitt, Sébastien Planel, Lisa Richard, Gioia Humbertjean, Jean-Christophe Mione, Nolwenn Lacour, Gérard Riou-Comte, Marcela Audibert, Lionel Voicu, Marie Alb, Madalina Reitter, Agnès Brezeanu, Adriana Masson, Iona Tabarna, Sarah Podar, Fatiha Guy, Fatiha Bechiri, Charbel Mounayer, Aymeric Rouchaud, Laetitia Gimenez, Alexandre Cosnard, Vincent Costalat, Grégory Gascou, Pierre-Henri Lefèvre, Imad Derraz, Carlos Riquelme, Nicolas Gaillard, Isabelle Mourand, Lucas Corti, Federico Cagnazzo, Adrien ter Schiphorst, Jean-Christophe Ferre, Hélène Raoult, Thomas Ronziere, Maria Lassale, Christophe Paya, Jean-Yves Gauvrit, Clément Tracol, Sophie Langnier-Lemercier, Axelle Maurice, Sabrina Cochennec, Mélanie Pinault, Eimad Shotar, Nader Sourour, Stéphanie Lenck, Kévin Premat, Yves Samson Anne Léger, Sophie Crozier, Flore Baronnet, Sonia Alamowitch, Laure Bottin, Mathon Yger, Vincent Degos, Olivier Chassin, Vanessa Chalumeau, Jildaz Caroff, Laura Venditti, Mariana Sarov, Nicolas Legris, Wagih Ben Hassen, Grégoire Boulouis, Christine Rodriguez-Régent, Denis Trystram, Basile Kerleroux, Valérie Domigo, Catherine Lamy, Julia Birchenall, Clothilde Isabel, François Lun, Anne Christine Januel, Jean-Marc Olivot, Nicolas Raposo, Fabrice Bonneville, Jean François Albucher, Lionel Calviere, Jean Darcourt, Guillaume Bellanger, Philippe Tall, Romain Schneckenburger, Marion Boulanger, Julien Cogez, Sophie Guettier, Maxime Gauberti, Julien Ognard, Francois Mathias Merrien., Ozlem Ozku Wermester, Evelyne Massardier, Aude Triquenot, Margeaux Lefebvre, Patricia Bernady, Laurent Lagoarde-Segot, Hélène Cailliez, David Higue, Veronique Quenardelle, Valerie Lauer, Roxana Gheoca, Irene Pierre-Paul, Remy Beaujeux, Dan Mihoc, Monica Manisor, Julien Pottecher, Alain Meyer, Thiên-Nga Chamaraux-Tran, Anthony Le Bras, Arnaud Le Guen, Norbert Nighoghossian, Roberto Riva, Omer Eker, Francis turjman, Laurent Derex, Tae-Hee Cho, Laura Mechtouff, Anne Claire Lukaszewicz, Frédéric Philippeau, Serkan Cakmak, Karine Blanc-Lasserre, and Anne-Evelyne Vallet

Subjects
Adult, Male, medicine.medical_specialty, Endovascular therapy, Brain ischemia, Internal medicine, medicine, Humans, Registries, Endovascular treatment, Prospective cohort study, Acute ischemic stroke, Acute stroke, Aged, Ischemic Stroke, Advanced and Specialized Nursing, business.industry, Endovascular Procedures, Middle Aged, medicine.disease, Embolic stroke, Treatment Outcome, Ischemic stroke, Cardiology, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Platelet Aggregation Inhibitors
Abstract

Background and Purpose: The influence of prior antiplatelet therapy (APT) uses on the outcomes of patients with acute ischemic stroke treated with endovascular therapy is unclear. We compared procedural and clinical outcomes of endovascular therapy in patients on APT or not before stroke onset. Methods: We analyzed 2 groups from the ongoing prospective multicenter Endovascular Treatment in Ischemic Stroke registry in France: patients on prior APT (APT+) and patients without prior APT (APT−) treated by endovascular therapy, with and without intravenous thrombolysis. Multilevel mixed-effects logistic models including center as random effect were used to compare angiographic (rates of reperfusion at the end of procedure, procedural complications) and clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) outcomes according to APT subgroups. Comparisons were adjusted for prespecified confounders (age, admission National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, intravenous thrombolysis, and time from onset to puncture), as well as for meaningful baseline between-group differences. Results: A total of 2939 patients were analyzed, of whom 877 (29.8%) were on prior APT. Patients with prior APT were older, had more frequent vascular risk factors, cardioembolic stroke mechanism, and prestroke disability. Rates of complete reperfusion (37.9% in the APT− group versus 42.7 % in the APT+ group; aOR, 1.09 [95% CI, 0.88–1.34]; P =0.41) and periprocedural complication (16.9% versus 13.3%; aOR, 0.90 [95% CI, 0.7–1.2]; P =0.66) did not differ between the two groups. Symptomatic intracerebral hemorrhage (aOR, 0.93 [95% CI, 0.63–1.37]; P =0.73), 3 months favorable clinical outcome (modified Rankin Scale score of 0–2; aOR, 0.98 [95% CI, 0.77–1.25]; P =0.89), and mortality (aOR, 0.95 [95% CI, 0.72–1.26]; P =0.76) at 90 days did not differ between the groups. Conclusions: Prior APT does not influence angiographic and functional outcomes following endovascular therapy and should not be taken into account for acute revascularization strategies.

Published
2021

11. European Stroke Organisation (ESO) standard operating procedure for the preparation and publishing of guidelines

Author

Pooja Khatri, Marialuisa Zedde, Eivind Berge, Terence J. Quinn, A. H. Aamodt, Simona Sacco, Danilo Toni, Martin Dichgans, Eleni Korompoki, J. Martí-Fabregas, Guillaume Turc, Blanca Fuentes, Bo Norrving, Timothy J. Steiner, and Hanne Christensen

Subjects
Process management, business.industry, Computer science, Process (engineering), GRADE (Recommendations Assessment, review, Guideline, Evidence-based medicine, Development, Guidelines, Publication Policy, Publishing, Review process, ddc:610, Neurology (clinical), and Evaluation), evidence-based medicine, guideline development, Cardiology and Cardiovascular Medicine, business, Grading (education), Standard operating procedure
Abstract

The first European Stroke Organization (ESO) standard operating procedure (SOP) published in 2015 aimed at the implementation the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to provide evidence-based guidelines for stroke management. This second ESO-SOP is aiming at further increase of the practicability of ESO guidelines and its technical implications. Authors comprised of the members of the ESO guideline Board and ESO Executive Committee. The final document was agreed on by several internal reviews. The second SOP comprises of the following aspects: rational for the SOP, the introduction of expert consensus statements, types of guideline documents, structures involved and detailed description of the guideline preparation process, handling of financial and intellectual conflicts of interest (CoI), involvement of ESO members in the guideline process, review process, authorship and publication policy, updating of guidelines, cooperation with other societies, and dealing with falsified data. This second SOP supersedes the first SOP published in 2015.

Published
2021
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12. Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions

Author

Didier Leys, Peter D. Schellinger, Pooja Khatri, Martin Köhrmann, Nitin Goyal, Adam S Arthur, Guillaume Turc, Aristeidis H. Katsanos, Georgios Magoufis, Niaz Ahmed, Christos Krogias, Andrei V. Alexandrov, Georgios Tsivgoulis, Konark Malhotra, and Mayank Goyal

Subjects
0301 basic medicine, medicine.medical_specialty, medicine.medical_treatment, Medizin, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Modified Rankin Scale, Internal medicine, Humans, Medicine, Thrombolytic Therapy, Thrombectomy, business.industry, Thrombolysis, Odds ratio, Combined Modality Therapy, Confidence interval, Stroke, Clinical trial, Mechanical thrombectomy, Treatment Outcome, 030104 developmental biology, Neurology, Meta-analysis, Cardiology, Administration, Intravenous, Observational study, Neurology (clinical), business, 030217 neurology & neurosurgery
Abstract

Objective The substantial clinical improvement in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT), combined with the poor response of proximal intracranial occlusions to intravenous thrombolysis (IVT), led to questions regarding the utility of bridging therapy (BT; IVT followed by MT) compared to direct mechanical thrombectomy (dMT) for AIS patients with large vessel occlusion (LVO). Methods We aimed to investigate the comparative safety and efficacy of BT and dMT in AIS patients. We included all observational studies and post hoc analyses from randomized controlled clinical trials that provided data on the outcomes of AIS patients with LVO stratified by IVT treatment status prior to MT. Results We identified 38 eligible observational studies (11,798 LVO patients, mean age = 68 years, 56% treated with BT). In unadjusted analyses, BT was associated with a higher likelihood of 3-month functional independence (odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.32-1.76), 3-month functional improvement (common OR [cOR] for 1-point decrease in modified Rankin Scale score = 1.52, 95% CI = 1.18-1.97), early neurological improvement (OR = 1.21, 95% CI = 1.83-1.76), successful recanalization (OR = 1.22, 95% CI = 1.02-1.46), and successful recanalization with ≤2 device passes (OR = 2.28, 95% CI = 1.43-3.64) compared to dMT. BT was also related to a lower likelihood of 3-month mortality (OR = 0.64, 95% CI = 0.57-0.73). In the adjusted analyses, BT was independently associated with a higher likelihood of 3-month functional independence (adjusted OR = 1.55, 95% CI = 1.26-1.91) and lower odds of 3-month mortality (adjusted OR = 0.80, 95% CI = 0.66-0.97) compared to dMT. The two groups did not differ in functional improvement (adjusted cOR = 1.24, 95% CI = 0.89-1.74) or symptomatic intracranial hemorrhage (adjusted OR = 0.87, 95% CI = 0.61-1.25). Interpretation BT appears to be associated with improved functional independence without evidence for safety concerns, compared to dMT, for AIS patients with LVO. ANN NEUROL 2019;86:395-406.

Published
2019
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13. Relationships between brain perfusion and early recanalization after intravenous thrombolysis for acute stroke with large vessel occlusion

Author

Cyril Dargazanli, Yves Berthezène, Sébastien Richard, Vincent Costalat, Serge Bracard, Pierre Seners, Séverine Debiais, Ana-Paula Narata, Caroline Arquizan, Canan Ozsancak, Christophe Magni, Jean-Philippe Cottier, Jean-Louis Mas, Benjamin Gory, Laurence Legrand, Stéphanie Lion, Guillaume Turc, Jean-Claude Baron, Catherine Oppenheim, Norbert Nighoghossian, Tae-Hee Cho, Olivier Naggara, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Service de neuroradiologie [Tours], Centre Hospitalier Régional Universitaire de Tours (CHRU Tours), Centre de Recherche en Acquisition et Traitement de l'Image pour la Santé (CREATIS), Université Jean Monnet [Saint-Étienne] (UJM)-Hospices Civils de Lyon (HCL)-Institut National des Sciences Appliquées de Lyon (INSA Lyon), Institut National des Sciences Appliquées (INSA)-Université de Lyon-Institut National des Sciences Appliquées (INSA)-Université de Lyon-Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Centre National de la Recherche Scientifique (CNRS)-Institut National de la Santé et de la Recherche Médicale (INSERM), Département de neurologie [Montpellier], Hôpital Gui de Chauliac [Montpellier]-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Université Montpellier 1 (UM1)-Université de Montpellier (UM), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Centre Hospitalier Régional d'Orléans (CHRO), Service de Neurologie [Tours], Centre Hospitalier Régional Universitaire de Tours (CHRU Tours)-Hôpital Bretonneau, Hôpital de la Croix-Rousse [CHU - HCL], Hospices Civils de Lyon (HCL), Département de Neuroradiologie[Montpellier], Service de neurologie [CHRU Nancy], Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Institut National des Sciences Appliquées de Lyon (INSA Lyon), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Gui de Chauliac [Montpellier]-Université de Montpellier (UM), Modeling & analysis for medical imaging and Diagnosis (MYRIAD), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), Martinez Rico, Clara, Centre Hospitalier Régional Universitaire de Tours (CHRU TOURS), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Université de Lyon-Institut National des Sciences Appliquées (INSA)-Université Claude Bernard Lyon 1 (UCBL), and Hôpital Bretonneau-Centre Hospitalier Régional Universitaire de Tours (CHRU Tours)

Subjects
Male, thrombolysis, medicine.medical_specialty, Mechanical Thrombolysis, [SDV]Life Sciences [q-bio], medicine.medical_treatment, Ischemia, Perfusion scanning, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Cerebral perfusion, Internal medicine, ischemic stroke, medicine, Humans, magnetic resonance imaging, Prospective Studies, Registries, [SDV.NEU] Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], cardiovascular diseases, Thrombus, Stroke, Aged, Retrospective Studies, Acute stroke, Aged, 80 and over, business.industry, Brain, Original Articles, Thrombolysis, Middle Aged, medicine.disease, Perfusion, [SDV] Life Sciences [q-bio], Diffusion Magnetic Resonance Imaging, Neurology, thrombectomy, Cardiology, Female, [SDV.NEU]Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Magnetic Resonance Angiography, 030217 neurology & neurosurgery, Large vessel occlusion
Abstract

In large vessel occlusion (LVO) stroke, it is unclear whether severity of ischemia is involved in early post-thrombolysis recanalization over and above thrombus site and length. Here we assessed the relationships between perfusion parameters and early recanalization following intravenous thrombolysis administration in LVO patients. From a multicenter registry, we identified 218 thrombolysed LVO patients referred for thrombectomy with both (i) pre-thrombolysis MRI, including diffusion-weighted imaging (DWI), T2*-imaging, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI); and (ii) evaluation of recanalization on first angiographic run or non-invasive imaging ≤ 3 h from thrombolysis start. Infarct core volume on DWI, PWI-DWI mismatch volume and hypoperfusion intensity ratio (HIR; defined as Tmax ≥ 10 s volume/ Tmax ≥ 6 s volume, low HIR indicating milder hypoperfusion) were determined using a commercially available software. Early recanalization occurred in 34 (16%) patients, and multivariable analysis was associated with lower HIR ( P = 0.006), shorter thrombus on T2*-imaging ( P

Published
2019
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14. Changes in Stroke Hospital Care During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Author

Aristeidis H. Katsanos, Andrei V. Alexandrov, Shadi Yaghi, Vassiliki Benetou, Konstantinos Vadikolias, Shima Shahjouei, Babak B. Navi, Luciana Catanese, Georgios Tsivgoulis, Hooman Kamel, Guillaume Turc, Sotirios Tsiodras, Konstantinos Tsioufis, Ramin Zand, Lina Palaiodimou, Pagona Lagiou, Dimitris Mavridis, Vivek Sharma, Ashkan Shoamanesh, Petros P. Sfikakis, McMaster University [Hamilton, Ontario], National and Kapodistrian University of Athens (NKUA), Geisinger Health System [Danville, PA, USA], New York University Langone Medical Center (NYU Langone Medical Center), NYU System (NYU), Weill Cornell Medicine [New York], Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), FHU NeuroVasc [Site Sainte-Anne, Paris] (GHU-PPN), Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université de Paris (UP), GHU Paris Psychiatrie et Neurosciences, Université de Paris (UP), National University of Singapore (NUS), University of Ioannina, Université Paris Descartes - Faculté de Médecine (UPD5 Médecine), Université Paris Descartes - Paris 5 (UPD5), Democritus University of Thrace (DUTH), Harvard T.H. Chan School of Public Health, The University of Tennessee Health Science Center [Memphis] (UTHSC), University General Hospital ' Attikon ' [Athens, Greece], National Public Health Organization [Athens, Greece] (NPHO Athens), Martinez Rico, Clara, Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Cité (UPCité), and Université Paris Cité (UPCité)

Subjects
medicine.medical_specialty, thrombolysis, Coronavirus disease 2019 (COVID-19), Original Contributions, medicine.medical_treatment, coronavirus, 030204 cardiovascular system & hematology, medicine.disease_cause, Severity of Illness Index, Clinical and Population Sciences, 03 medical and health sciences, 0302 clinical medicine, Pandemic, Odds Ratio, medicine, ischemic stroke, Humans, Thrombolytic Therapy, Hospital Mortality, Stroke, Coronavirus, Advanced and Specialized Nursing, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, SARS-CoV-2, business.industry, Endovascular Procedures, COVID-19, Thrombolysis, medicine.disease, mortality, Hospital care, 3. Good health, Treatment Outcome, thrombectomy, Meta-analysis, Emergency medicine, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Observational study, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Delivery of Health Care, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, hospitalization
Abstract

Supplemental Digital Content is available in the text., Background and Purpose: We systematically evaluated the impact of the coronavirus 2019 (COVID-19) pandemic on stroke care across the world. Methods: Observational studies comparing characteristics, acute treatment delivery, or hospitalization outcomes between patients with stroke admitted during the COVID-19 pandemic and those admitted before the pandemic were identified by Medline, Scopus, and Embase databases search. Random-effects meta-analyses were conducted for all outcomes. Results: We identified 46 studies including 129 491 patients. Patients admitted with stroke during the COVID-19 pandemic were found to be younger (mean difference, −1.19 [95% CI, −2.05 to −0.32]; I2=70%) and more frequently male (odds ratio, 1.11 [95% CI, 1.01–1.22]; I2=54%) compared with patients admitted with stroke in the prepandemic era. Patients admitted with stroke during the COVID-19 pandemic, also, had higher baseline National Institutes of Health Stroke Scale scores (mean difference, 0.55 [95% CI, 0.12–0.98]; I2=90%), higher probability for large vessel occlusion presence (odds ratio, 1.63 [95% CI, 1.07–2.48]; I2=49%) and higher risk for in-hospital mortality (odds ratio, 1.26 [95% CI, 1.05–1.52]; I2=55%). Patients with acute ischemic stroke admitted during the COVID-19 pandemic had higher probability of receiving endovascular thrombectomy treatment (odds ratio, 1.24 [95% CI, 1.05–1.47]; I2=40%). No difference in the rates of intravenous thrombolysis administration or difference in time metrics regarding onset to treatment time for intravenous thrombolysis and onset to groin puncture time for endovascular thrombectomy were detected. Conclusions: The present systematic review and meta-analysis indicates an increased prevalence of younger patients, more severe strokes attributed to large vessel occlusion, and higher endovascular treatment rates during the COVID-19 pandemic. Patients admitted with stroke during the COVID-19 pandemic had higher in-hospital mortality. These findings need to be interpreted with caution in view of discrepant reports and heterogeneity being present across studies.

Published
2021
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15. Cerebral amyloid angiopathy-related acute lobar intra-cerebral hemorrhage: diagnostic value of plain CT

Author

Gregoire Boulouis, Joseph Benzakoun, Catherine Oppenheim, Corentin Schwall, Guillaume Turc, Jean-Claude Baron, Pascale Varlet, GHU AP-HP Centre Université de Paris, Université de Paris (UP), Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm - Paris Descartes), Université Paris Descartes - Paris 5 (UPD5)-Institut National de la Santé et de la Recherche Médicale (INSERM), CHU Trousseau [Tours], Centre Hospitalier Régional Universitaire de Tours (CHRU Tours), Université Paris Cité (UPCité), and Martinez Rico, Clara

Subjects
Finger-like projections, medicine.medical_specialty, Subarachnoid hemorrhage, Neurology, Autopsy, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Hematoma, medicine, Pathology, Humans, In patient, [SDV.NEU] Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], cardiovascular diseases, Prospective Studies, Neuroradiology, Aged, Cerebral Hemorrhage, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, business.industry, Reproducibility of Results, Middle Aged, medicine.disease, Magnetic Resonance Imaging, 3. Good health, nervous system diseases, Boston criteria, Cerebral Amyloid Angiopathy, Cohort, [SDV.NEU]Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Neurology (clinical), Cerebral amyloid angiopathy, Radiology, business, Tomography, X-Ray Computed, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, MRI
Abstract

Background Diagnosing probable cerebral amyloid angiopathy (CAA) after lobar intra-cerebral hemorrhage (l-ICH) currently relies on the MR-based modified Boston criteria (mBC). However, MRI has limited availability and the mBC have moderate sensitivity, with isolated l-ICH being classified as “possible CAA”. A recent autopsy-based study reported potential value of finger-like projections (FLP) and subarachnoid hemorrhage (SAH) on acute CT. Here we assessed these markers’ performance in a cohort most of whom survived the index episode. Methods We included all patients from a prospective pathology database with non-traumatic l-ICH, admission CT and available tissue sample showing no alternative cause. CT was assessed by two blinded independent neuroradiologists. Interobserver reproducibility was almost perfect for SAH and substantial for FLP. Results Sixteen patients were eligible [age 65.8 ± 7.2 yrs; hematoma volume: 39(26, 71)mls; hematoma evacuation sample 15 patients; autopsy one patient]. MRI was available in 11 patients. ICH-related death affected six patients. Aβ40–42 immunohistochemistry revealed CAA in seven patients (44%). SAH and FLP were present in 12/16 (75%) and 10/16 (62%) patients, respectively. SAH had 100% sensitivity for CAA but low specificity; FLP had lower performance. Using either pathology or MRI as reference standard yielded essentially similar results. All patients with possible CAA on MRI but CAA on pathology had SAH. Conclusions In patients with moderate-size l-ICH who mostly survived the index event, SAH had perfect sensitivity and better performance than FLP. In addition, SAH appeared to add onto MRI in possible CAA, the clinically most relevant scenario. Studies in larger samples are however warranted.

Published
2021
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16. Perfusion imaging and clinical outcome in acute ischemic stroke with large core

Author

Patrice Menegon, Michael Mlynash, Laurence Legrand, Sylvain Charron, Frame Investigators, Nicolas Raposo, Adrien Guenego, Mikael Mazighi, Fabrice Bonneville, Christophe Cognard, Lionel Calviere, Jean Darcourt, Vanessa Rousseau, Agnès Sommet, Alain Viguier, Guillaume Turc, Jean-Claude Baron, Anne-Christine Januel, Igor Sibon, Pierre Seners, Claire Thalamas, Thomas Tourdias, Soren Christensen, Jean-François Albucher, Catherine Oppenheim, Gregory W. Albers, Jean-Marc Olivot, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Hôpital Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Hôpital Pierre-Paul Riquet [Toulouse], CHU Toulouse [Toulouse], Stanford University, CHU Bordeaux [Bordeaux], FRAME investigators: François Chollet, Louis Fontaine, Marianne Barbieux, Caterina Michelozzi, Philippe Tall, François Caparros, Brigitte Pouzet, Fabienne Calvas, Monique Galitzki, Amel Drif, Pauline Renou, François Rouanet, Jerome Berge, Gauthier Marnat, Patrice Menegon, Ludovic Lucas, Cyrielle Coignon, Sharmila Sagnier, Sabrina Debruxelle, Sylvain Ledure, Martinez Rico, Clara, Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), and Centre Hospitalier Universitaire de Toulouse (CHU Toulouse)

Subjects
Male, medicine.medical_specialty, medicine.medical_treatment, Perfusion Imaging, Perfusion scanning, Brain Ischemia, Cohort Studies, Text mining, Modified Rankin Scale, Internal medicine, medicine, Humans, Prospective Studies, Prospective cohort study, Aged, Retrospective Studies, Thrombectomy, Aged, 80 and over, Core (anatomy), [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, business.industry, Penumbra, Thrombolysis, Middle Aged, Magnetic Resonance Imaging, 3. Good health, Stroke, Treatment Outcome, Neurology, Cardiology, Female, Neurology (clinical), business, Tomography, X-Ray Computed, Perfusion, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, Follow-Up Studies
Abstract

International audience; Objective: Mechanical thrombectomy (MT) is not recommended for acute stroke with large vessel occlusion (LVO) and a large volume of irreversibly injured tissue (“core”). Perfusion imaging may identify a subset of patients with large core who benefit from MT.Methods: We compared two cohorts of LVO-related patients with large core (>50 ml on diffusion-weighted-imaging or CT-perfusion using RAPID), available perfusion imaging, and treated within 6 hrs from onset by either MT + Best Medical Management (BMM) in one prospective study, or BMM alone in the pre-MT era from a prospective registry. Primary outcome was 90-day modified Rankin Scale≤2. We searched for an interaction between treatment group and amount of penumbra as estimated by the mismatch ratio (MMRatio = critical hypoperfusion/core volume).Results: Overall, 107 patients were included (56 MT + BMM + 51 BMM): Mean age was 68 ± 15 yrs, median core volume 99 ml (IQR: 72-131) and MMRatio 1.4 (IQR: 1.0-1.9). Baseline clinical and radiological variables were similar between the 2 groups, except for a higher intravenous thrombolysis rate in the BMM group. The MMRatio strongly modified the clinical outcome following MT (Pinteraction < 0.001 for continuous MMRatio); MT was associated with a higher rate of good outcome in patients with, but not in those without, MMRatio>1.2 (adjusted OR [95%CI] = 6.8 [1.7-27.0] vs. 0.7 [0.1-6.2], respectively). Similar findings were present for MMRatio≥1.8 in the subgroup with core≥70 ml. Parenchymal hemorrhage on follow-up imaging was more frequent in the MT + BMM group regardless of the MMRatio.Interpretation: Perfusion imaging may help select which patients with large core should be considered for MT. Randomized studies are warranted. This article is protected by copyright. All rights reserved.

Published
2021
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17. Editorial: Patent Foramen Ovale (PFO) Closure for Prevention of Stroke

Author

Harsimran Singh, George Giannakoulas, Vincent Thijs, Guillaume Turc, Damianos G Kokkinidis, Aristeidis H. Katsanos, Yale University School of Medicine, McMaster University [Hamilton, Ontario], AHEPA University General Hospital [Thessaloniki], Weill Cornell Medicine [New York], New York Presbyterian Hospital, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), FHU NeuroVasc [Site Sainte-Anne, Paris] (GHU-PPN), Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université de Paris (UP), GHU Paris Psychiatrie et Neurosciences, Université de Paris (UP), The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Martinez Rico, Clara, Yale School of Medicine [New Haven, Connecticut] (YSM), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Cité (UPCité), and Université Paris Cité (UPCité)

Subjects
medicine.medical_specialty, [SDV]Life Sciences [q-bio], patent foramen ovale, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Pfo closure, Internal medicine, medicine, 030212 general & internal medicine, PFO closure device, RC346-429, Stroke, ComputingMilieux_MISCELLANEOUS, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, business.industry, medicine.disease, stroke, 3. Good health, Clinical neurology, [SDV] Life Sciences [q-bio], Cryptogenic stroke, PFO - Patent foramen ovale, Neurology, Stroke prevention, Patent foramen ovale, Cardiology, cryptogenic stroke, stroke prevention, Neurology. Diseases of the nervous system, Neurology (clinical), business, Medical therapy, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

International audience; No abstract available

Published
2021
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18. Letter to the editor: Serum anti-Aβ antibodies in cerebral amyloid angiopathy

Author

Thomas de Broucker, Anne Wacongne, Yannick Chantran, Marie Sarazin, Guillaume Dorothée, Corina Cret, Sonia Alamowitch, Johanna Felix, Diana Doukhi, Florian Kruse, Guillaume Turc, Xavier Ayrignac, Pierre Aucouturier, Charlotte Cordonnier, Thomas Chaigneau, Jean Capron, Mélanie Féroul, Roxane Peres, Zina Barrou, Dimitri Renard, Thibault Allou, Pathologies biliaires, fibrose et cancer du foie [CHU Saint-Antoine], Centre de Recherche Saint-Antoine (CR Saint-Antoine), Sorbonne Université (SU)-Institut National de la Santé et de la Recherche Médicale (INSERM)-CHU Saint-Antoine [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Sorbonne Université (SU)-Institut National de la Santé et de la Recherche Médicale (INSERM)-CHU Saint-Antoine [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Centre Hospitalier Saint Jean de Perpignan, Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Service de gériatrie [CHU Pitié-Salpêtrière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Sorbonne Université (SU), Centre Hospitalier de Saint-Denis [Ile-de-France], Centre Hospitalier de Meaux, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Hôpital Lariboisière-Fernand-Widal [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Hôpital Universitaire Carémeau [Nîmes] (CHU Nîmes), Centre Hospitalier Universitaire de Nîmes (CHU Nîmes), Centre Hospitalier Sainte Anne [Paris], Lille Neurosciences & Cognition - U 1172 (LilNCog (ex-JPARC)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Aucouturier, Pierre, Pathologies biliaires, fibrose et cancer du foie [CRSA], Centre de Recherche Saint-Antoine (CRSA), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU), Service de Médecine Gériatrique [CHU Pitié-Salpêtrière], CHU Pitié-Salpêtrière [AP-HP], Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Lille Neurosciences & Cognition - U 1172 (LilNCog), Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU), Système immunitaire et neuroinflammation [CRSA], CHU Saint-Antoine [AP-HP], and Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)

Subjects
Pathology, medicine.medical_specialty, Letter to the editor, Immunology, Aβ-related angiitis, 03 medical and health sciences, 0302 clinical medicine, natural antibodies, medicine, Immunology and Allergy, Humans, Stroke, cerebral amyloid angiopathy, ComputingMilieux_MISCELLANEOUS, 030203 arthritis & rheumatology, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, Amyloid beta-Peptides, biology, business.industry, medicine.disease, stroke, Peptide Fragments, 3. Good health, [SDV.IMM.IA]Life Sciences [q-bio]/Immunology/Adaptive immunology, [SDV.IMM.IA] Life Sciences [q-bio]/Immunology/Adaptive immunology, anti-Aβ antibodies, biology.protein, Cerebral amyloid angiopathy, Antibody, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

International audience; No abstract available

Published
2021
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19. Cathodal Transcranial Direct Current Stimulation in Acute Ischemic Stroke: Pilot Randomized Controlled Trial

Author

Catherine Lamy, Martine Gavaret, Jean-Louis Mas, Rossella Letizia Mancusi, Guillaume Turc, David Calvet, Joseph Benzakoun, Jean-Claude Baron, V. Domigo, Estelle Pruvost-Robieux, Angela Marchi, and Catherine Oppenheim

Subjects
Male, medicine.medical_specialty, medicine.medical_treatment, Transcranial Direct Current Stimulation, Neuroprotection, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, Double-Blind Method, law, medicine.artery, Internal medicine, medicine, Humans, 030212 general & internal medicine, Acute ischemic stroke, Aged, Ischemic Stroke, Advanced and Specialized Nursing, Aged, 80 and over, medicine.diagnostic_test, Transcranial direct-current stimulation, business.industry, Magnetic resonance imaging, Middle Aged, Magnetic Resonance Imaging, Middle cerebral artery, Acute Disease, Cardiology, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery
Abstract

Background and Purpose: In acute stroke, preventing infarct growth until complete recanalization occurs is a promising approach as an adjunct to reperfusion therapies to reduce infarct size and improve outcome. In rodent models, cathodal transcranial direct current stimulation (C-tDCS) decreases peri-infarct depolarizations and reduces infarct volume. We hypothesized that C-tDCS would nonpharmacologically reduce infarct growth in hyperacute middle cerebral artery territory stroke patients receiving reperfusion therapy. Methods: STICA (Cathodal Transcranial Direct Stimulation in Acute Middle Cerebral Artery Stroke) was a pilot single-center, double-blind, 2-arms 1:1 randomized trial evaluating the safety, feasibility, and efficacy of C-tDCS versus sham stimulation in patients eligible for recanalization therapies. Magnetic resonance imaging was obtained both on admission and 24 hours later. The primary end point was 24-hour infarct growth. Secondary outcomes were (1) National Institutes of Health Stroke Scale score difference between day 7 and admission and (2) 3-month modified Rankin Scale score. Results: Forty-five patients were randomized. Median magnetic resonance imaging-to-C-tDCS start time was 45 minutes; C-tDCS was started before completion of recanalization procedure in all patients. The intervention proved feasible in all patients. No major adverse effects occurred in either group. There was no significant difference between active and sham groups for any end point. However, an apparent trend towards smaller infarct growth in the C-tDCS arm was observed in the whole group (unadjusted median difference [IC 95% ]: −2.2 mL [−12.2 to 1.5]) and in the prespecified subsamples with moderate-to-severe stroke and large vessel occlusion (−5.7 mL [−21.6 to 2.6] and −7.7 mL [−24.2 to 2.6], respectively). Conclusions: C-tDCS was feasible and well tolerated. No significant difference was found between the active and sham groups. However, the data suggest potential benefits of C-tDCS in patients with National Institutes of Health Stroke Scale score of >10 or large vessel occlusion. Using the observed effect size and standard α=5% and β=20%, samples of 102 and 86, respectively, can be estimated for future trials in patients with these characteristics. Randomized trials particularly targeting these populations may be warranted.

Published
2021

20. Abstract P82: The Impact of SARS-COV-2 on Stroke Epidemiology and Care: A Meta-Analysis

Author

Lina Palaiodimou, Konstantinos Tsioufis, Konstantinos Vadikolias, Georgios Tsivgoulis, Pagona Lagiou, Hooman Kamel, Dimitris Mavridis, Ashkan Shoamanesh, Aristeidis H. Katsanos, Luciana Catanese, Sotirios Tsiodras, Guillaume Turc, Shadi Yaghi, Michele Romoli, Ramin Zand, Vivek Sharma, Shima Shahjouei, Babak B. Navi, and Andrei V Alexandrov

Subjects
Advanced and Specialized Nursing, Intracerebral hemorrhage, medicine.medical_specialty, business.industry, Odds ratio, Disease, medicine.disease, Meta-analysis, Diabetes mellitus, Internal medicine, Epidemiology, Medicine, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Stroke, Cohort study
Abstract

Background: Emerging data indicates an increased risk for cerebrovascular events with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and highlights the potential impact of coronavirus disease (COVID-19) on the management and outcomes of acute stroke. We conducted a systematic review and meta-analysis to evaluate the aforementioned considerations. Methods: We performed a meta-analysis of observational cohort studies reporting on the occurrence and/or outcomes of patients with cerebrovascular events in association with their SARS-CoV-2 infection status. We used a random-effects model. Summary estimates were reported as odds ratios (ORs) and corresponding 95% confidence intervals (95%CI). Results: We identified 16 cohort studies including 44,004 patients. Among patients with SARS-CoV-2, 1.3% (95%CI: 0.9-1.8%; I 2 =88%) were hospitalized for cerebrovascular events, 1.2% (95%CI: 0.8-1.5%; I 2 =85%) for ischemic stroke, and 0.2% (95%CI: 0.1-0.4%; I 2 =69%) for hemorrhagic stroke. Compared to non-infected contemporary or historical controls, patients with SARS-CoV-2 infection had increased odds of ischemic stroke (OR=3.58, 95%CI: 1.43-8.92; I 2 =43%) and cryptogenic stroke (OR=3.98, 95%CI: 1.62-9.77; I 2 =0%). Odds for in-hospital mortality were higher among SARS-CoV-2 stroke patients compared to non-infected contemporary or historical stroke patients (OR=5.60, 95%CI: 3.19-9.80; I 2 =45%). SARS-CoV-2 infection status was not associated to the likelihood of receiving intravenous thrombolysis (OR=1.42, 95%CI: 0.65-3.10; I 2 =0%) or endovascular thrombectomy (OR=0.78, 95%CI: 0.35-1.74; I 2 =0%) among hospitalized ischemic stroke patients during the COVID-19 pandemic. Diabetes mellitus was found to be more prevalent among SARS-CoV-2 stroke patients compared to non-infected contemporary or historical controls (OR=1.39, 95%CI: 1.04-1.86; I 2 =0%). Conclusion: SARS-CoV-2 appears to be associated with an increased risk of ischemic stroke, particularly the cryptogenic subtype. SARS-CoV-2 infection in stroke substantially increases the mortality risk.

Published
2021
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21. Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data

Author

Götz Thomalla, Florent Boutitie, Henry Ma, Masatoshi Koga, Peter Ringleb, Lee H Schwamm, Ona Wu, Martin Bendszus, Christopher F Bladin, Bruce C V Campbell, Bastian Cheng, Leonid Churilov, Martin Ebinger, Matthias Endres, Jochen B Fiebach, Mayumi Fukuda-Doi, Manabu Inoue, Timothy J Kleinig, Lawrence L Latour, Robin Lemmens, Christopher R Levi, Didier Leys, Kaori Miwa, Carlos A Molina, Keith W Muir, Norbert Nighoghossian, Mark W Parsons, Salvador Pedraza, Peter D Schellinger, Stefan Schwab, Claus Z Simonsen, Shlee S Song, Vincent Thijs, Danilo Toni, Chung Y Hsu, Nils Wahlgren, Haruko Yamamoto, Nawaf Yassi, Sohei Yoshimura, Steven Warach, Werner Hacke, Kazunori Toyoda, Geoffrey A Donnan, Stephen M Davis, Christian Gerloff, Boris Raul Acosta, Karen Aegidius, Christian Albiker, Anna Alegiani, Miriam Almendrote, Angelika Alonso, Katharina Althaus, Pierre Amarenco, Hemasse Amiri, Bettina Anders, Adriana Aniculaesei, Jason Appleton, Juan Arenillas, Christina Back, Christian Bähr, Jürgen Bardutzky, Flore Baronnet-Chauvet, Rouven Bathe-Peters, Anna Bayer-Karpinska, Juan L. Becerra, Christoph Beck, Olga Belchí Guillamon, Amandine Benoit, Nadia Berhoune, Daniela Bindila, Julia Birchenall, Karine Blanc-Lasserre, Miguel Blanco Gonzales, Tobias Bobinger, Ulf Bodechtel, Eric Bodiguel, Urszula Bojaryn, Louise Bonnet, Benjamin Bouamra, Paul Bourgeois, Lorenz Breuer, Ludovic Breynaert, David Broughton, Raf Brouns, Sébastian Brugirard, Bart Bruneel, Florian Buggle, Serkan Cakmak, Ana Calleja, David Calvet, David Carrera, Hsin-Chieh Chen, Bharath Cheripelli, Tae-Hee Cho, Chi-un Choe, Lillian Choy, Hanne Christensen, Mareva Ciatipis, Geoffrey Cloud, Julien Cogez, Elisa Cortijo, Sophie Crozier, Dorte Damgaard, Krishna Dani, Beatrijs De Coene, Isabel De Hollander, Jacques De Keyser, Nina De Klippel, Charlotte De Maeseneire, Ann De Smedt, Maria del Mar Castellanos Rodrigo, Sandrine Deltour, Jelle Demeestere, Laurent Derex, Philippe Desfontaines, Ralf Dittrich, Anand Dixit, Laurens Dobbels, Valérie Domigo, Laura Dorado, Charlotte Druart, Kristina Hougaard Dupont, Anne Dusart, Rainer Dziewas, Matthias Ebner, Myriam Edjali-Goujon, Philipp Eisele, Salwa El Tawil, Ahmed Elhfnawy, Ana Etexberria, Nicholas Evans, Simon Fandler, Franz Fazekas, Sandra Felix, Jochen B. Fiebach, Jens Fiehler, Alexandra Filipov, Katharina Filipski, Robert Fleischmann, Christian Foerch, Ian Ford, Alexandra Gaenslen, Ivana Galinovic, Elena Meseguer Gancedo, Ramanan Ganeshan, Carlos García Esperón, Alicia Garrido, Thomas Gattringer, Olivia Geraghty, Rohat Geran, Stefan Gerner, Sylvie Godon-Hardy, Jos Göhler, Amir Golsari, Meritxell Gomis, David Gorriz, Verena Gramse, Laia Grau, Martin Griebe, Cristina Guerrero, Damla Guerzoglu, Sophie Guettier, Vincent Guiraud, Christoph Gumbinger, Ignaz Gunreben, Florian Haertig, Christian Hametner, Bernard Hanseeuw, Andreas Hansen, Jakob Hansen, Thomas Harbo, Andreas Harloff, Peter Harmel, Karl Georg Häusler, Florian Heinen, Valentin Held, Simon Hellwig, Dimitri Hemelsoet, Michael Hennerici, Juliane Herm, Sylvia Hermans, María Hernández, Jose Hervas Vicente, Niels Hjort, Cristina Hobeanu, Carsten Hobohm, Elmar Höfner, Katharina Hohenbichler, Marc Hommel, Julia Hoppe, Eva Hornberger, Carolin Hoyer, Xuya Huang, Nils Ipsen, Irina Isern, Lourdes Ispierto, Helle Iversen, Lise Jeppesen, Marta Jimenez, Jan Jungehülsing, Eric Jüttler, Dheeraj Kalladka, Bernd Kallmünzer, Arindam Kar, Lars Kellert, André Kemmling, Tobias Kessler, Usman Khan, Matthias Klein, Christoph Kleinschnitz, Matti Klockziem, Michael Knops, Luzie Koehler, Martin Koehrmann, Heinz Kohlfürst, Rainer Kollmar, Peter Kraft, Thomas Krause, Bo Kristensen, Jan M. Kröber, Natalia Kurka, Alexandre Ladoux, Patrice Laloux, Catherine Lamy, Emmanuelle Landrault, Arne Lauer, Claire Lebely, Jonathan Leempoel, Kennedy Lees, Anne Leger, Laurence Legrand, Lin Li, Anna-Mareike Löbbe, Frederic London, Elena Lopez-cancio, Matthias Lorenz, Stephen Louw, Caroline Lovelock, Manuel Lozano Sánchez, Giuseppe Lucente, Janos Lückl, Alain Luna, Kosmas Macha, Alexandre Machet, Daniel Mackenrodt, Dominik Madzar, Charles Majoie, Anika Männer, Vicky Maqueda, Jacob Marstrand, Alicia Martinez, Annika Marzina, Laura Mechthouff, Per Meden, Guy Meersman, Julia Meier, Charles Mellerio, Oliver Menn, Nadja Meyer, Dominik Michalski, Peter Michels, Lene Michelsen, Monica Millán Torne, Jens Minnerup, Boris Modrau, Sebastian Moeller, Anette Møller, Nathalie Morel, Fiona Moreton, Ludovic Morin, Thierry Moulin, Barry Moynihan, Anne K. Mueller, Keith W. Muir, Patricia Mulero, Sibu Mundiyanapurath, Johannes Mutzenbach, Simon Nagel, Oliver Naggara, Arumugam Nallasivan, Irene Navalpotro, Alexander H. Nave, Paul Nederkoorn, Lars Neeb, Hermann Neugebauer, Tobias Neumann-Haefelin, Stefan Oberndorfer, Christian Opherk, Lorenz Oppel, Catherine Oppenheim, Johannes Orthgieß, Leif Ostergaard, Perrine Paindeville, Ernest Palomeras, Verena Panitz, Bhavni Patel, Andre Peeters, Dirk Peeters, Anna Pellisé, Johann Pelz, Anthony Pereira, Natalia Pérez de la Ossa, Richard Perry, Salvador Petraza, Stéphane Peysson, Waltraud Pfeilschifter, Alexander Pichler, Alexandra Pierskalla, Hans-Werner Pledl, Sven Poli, Katrin Pomrehn, Marika Poulsen, Luis Prats, Silvia Presas, Elisabeth Prohaska, Volker Puetz, Josep Puig, Josep Puig Alcántara, Jan Purrucker, Veronique Quenardelle, Sankaranarayanan Ramachandran, Soulliard Raphaelle, Nicolas Raposo, Tilman Reiff, Michel Remmers, Pauline Renou, Martin Ribitsch, Hardy Richter, Martin Ritter, Thomas Ritzenthaler, Gilles Rodier, Christine Rodriguez-Regent, Manuel Rodríguez-Yáñez, Maria Roennefarth, Christine Roffe, Sverre Rosenbaum, Charlotte Rosso, Joachim Röther, Michal Rozanski, Noelia Ruiz de Morales, Francesca Russo, Matthieu Rutgers, Sharmilla Sagnier, Yves Samson, Josep Sánchez, Tamara Sauer, Jan H. Schäfer, Simon Schieber, Josef Schill, Dennis Schlak, Ludwig Schlemm, Sein Schmidt, Wouter Schonewille, Julian Schröder, Andreas Schulz, Johannes Schurig, Sönke Schwarting, Alexander Schwarz, Christopher Schwarzbach, Matthias Seidel, Alexander Seiler, Jochen Sembill, Joaquin Serena Leal, Ashit Shetty, Igor Sibon, Claus Z. Simonsen, Oliver Singer, Aravinth Sivagnanaratham, Ide Smets, Craig Smith, Peter Soors, Nikola Sprigg, Maximilian Spruegel, David Stark, Susanne Steinert, Sebastian Stösser, Markus Stuermlinger, Bart Swinnen, Ruben Tamazyan, Jose Tembl, Mikel Terceno Izaga, Emmanuel Touze, Thomas Truelsen, Guillaume Turc, Gaetane Turine, Serdar Tütüncü, Pippa Tyrell, Xavier Ustrell, Wilfried Vadot, Anne-Evelyne Vallet, Pauline Vallet, Lucie van den Berg, Sophie van den Berg, Cecile van Eendenburg, Robbert-Jan Van Hooff, Isabelle van Sloten, Peter Vanacker, Evelien Vancaester, Patrick Vanderdonckt, Yves Vandermeeren, Frederik Vanhee, Roland Veltkamp, Karsten Vestergaard, Alain Viguier, Dolores Vilas, Kersten Villringer, Dieke Voget, Jörg von Schrader, Paul von Weitzel, Elisabeth Warburton, Claudia Weber, Jörg Weber, Karl Wegscheider, Mirko Wegscheider, Christian Weimar, Karin Weinstich, Christopher Weise, Gesa Weise, Chris Willems, Klemens Winder, Matthias Wittayer, Marc Wolf, Martin Wolf, Valerie Wolff, Christian Wollboldt, Frank Wollenweber, Anke Wouters, Bertrand Yalo, Marion Yger, Nadia Younan, Laetita Yperzeele, Vesna Zegarac, Pia Zeiner, Ulf Ziemann, Thomas Zonneveld, Mathieu Zuber, Tsugio Akutsu, Junya Aoki, Shuji Arakawa, Ryosuke Doijiri, Yusuke Egashira, Yukiko Enomoto, Eisuke Furui, Konosuke Furuta, Seiji Gotoh, Toshimitsu Hamasaki, Yasuhiro Hasegawa, Teryuki Hirano, Kazunari Homma, Masahiko Ichijyo, Toshihiro Ide, Shuichi Igarashi, Yasuyuki Iguchi, Masafumi Ihara, Hajime Ikenouchi, Tsuyoshi Inoue, Ryo Itabashi, Yasuhiro Ito, Toru Iwama, Kenji Kamiyama, Shoko Kamiyoshi, Haruka Kanai, Yasuhisa Kanematsu, Takao Kanzawa, Kazumi Kimura, Jiro Kitayama, Takanari Kitazono, Rei Kondo, Kohsuke Kudo, Masayoshi Kusumi, Ken Kuwahara, Shoji Matsumoto, Hideki Matsuoka, Ban Mihara, Kazuo Minematsu, Ken Miura, Naomi Morita, Wataru Mouri, Kayo Murata, Yoshinari Nagakane, Taizen Nakase, Hiromi Ohara, Nobuyuki Ohara, Hideyuki Ohnishi, Hajime Ohta, Masafumi Ohtaki, Ryo Ohtani, Toshiho Ohtsuki, Hideo Ohyama, Takashi Okada, Yasushi Okada, Masato Osaki, Nobuyuki Sakai, Yoshiki Sanbongi, Naoshi Sasaki, Makoto Sasaki, Shoichiro Sato, Kenta Seki, Wataru Shimizu, Yoshiaki Shiokawa, Takashi Sozu, Junichiro Suzuki, Rieko Suzuki, Yasushi Takagi, Shunya Takizawa, Norio Tanahashi, Eijiro Tanaka, Ryota Tanaka, Yohei Tateishi, Tomoaki Terada, Tadashi Terasaki, Kenichi Todo, Azusa Tokunaga, Akira Tsujino, Toshihiro Ueda, Yoshikazu Uesaka, Mihoko Uotani, Takao Urabe, Masao Watanabe, Yoshiki Yagita, Yusuke Yakushiji, Keizo Yasui, Toshiro Yonehara, Shinichi Yoshimura, K. Aarnio, F. Alemseged, C. Anderson, T. Ang, M.L. Archer, J. Attia, P. Bailey, A. Balabanski, A. Barber, P.A. Barber, J. Bernhardt, A. Bivard, D. Blacker, C.F. Bladin, A. Brodtmann, D. Cadilhac, B.C.V. Campbell, L. Carey, S. Celestino, L. Chan, W.H. Chang, A. ChangI, C.H. Chen, C.-I. Chen, H.F. Chen, T.C. Chen, W.H. Chen, Y.Y. Chen, C.A. Cheng, E. Cheong, Y.W. Chiou, P.M. Choi, H.J. Chu, C.S. Chuang, T.C. Chung, L. Churilov, B. Clissold, A. Connelly, S. Coote, B. Coulton, E. Cowley, J. Cranefield, S. Curtze, C. D'Este, S.M. Davis, S. Day, P.M. Desmond, H.M. Dewey, C. Ding, G.A. Donnan, R. Drew, S. Eirola, D. Field, T. Frost, C. Garcia-Esperon, K. George, R. Gerraty, R. Grimley, Y.C. Guo, G. Hankey, J. Harvey, S.C. Ho, K. Hogan, D. Howells, P.M. Hsiao, C.H. Hsu, C.T. Hsu, C.-S. Hsu, J.P. Hsu, Y.D. Hsu, Y.T. Hsu, C.J. Hu, C.C. Huang, H.Y. Huang, M.Y. Huang, S.C. Huang, W.S. Huang, D. Jackson, J.S. Jeng, S.K. Jiang, L. Kaauwai, O. Kasari, J. King, T.J. Kleinig, M. Koivu, J. Kolbe, M. Krause, C.W. Kuan, W.L. Kung, C. Kyndt, C.L. Lau, A. Lee, C.Y. Lee, J.T. Lee, Y. Lee, Y.C. Lee, C. Levi, C.R. Levi, L.M. Lien, J.C. Lim, C.C. Lin, C.H. Lin, C.M. Lin, D. Lin, C.H. Liu, J. Liu, Y.C. Lo, P.S. Loh, E. Low, C.H. Lu, C.J. Lu, M.K. Lu, J. Ly, H. Ma, L. Macaulay, R. Macdonnell, E. Mackey, M. Macleod, J. Mahadevan, V. Maxwell, R. McCoy, A. McDonald, S. McModie, A. Meretoja, S. Mishra, P.J. Mitchell, F. Miteff, A. Moore, C. Muller, F. Ng, F.C. Ng, J-L. Ng, W. O'Brian, V. O'Collins, T.J. Oxley, M.W. Parsons, S. Patel, G.S. Peng, L. Pesavento, T. Phan, E. Rodrigues, Z. Ross, A. Sabet, M. Sallaberger, P. Salvaris, D. Shah, G. Sharma, G. Sibolt, M. Simpson, S. Singhal, B. Snow, N. Spratt, R. Stark, J. Sturm, M.C. Sun, Y. Sun, P.S. Sung, Y.F. Sung, M. Suzuki, M. Tan, S.C. Tang, T. Tatlisumak, V. Thijs, M. Tiainen, C.H. Tsai, C.K. Tsai, C.L. Tsai, H.T. Tsai, L.K. Tsai, C.H. Tseng, L.T. Tseng, J. Tsoleridis, H. Tu, H.T-H. Tu, W. Vallat, J. Virta, W.C. Wang, Y.T. Wang, M. Waters, L. Weir, T. Wijeratne, C. Williams, W. Wilson, A.A. Wong, K. Wong, T.Y. Wu, Y.H. Wu, B. Yan, F.C. Yang, Y.W. Yang, N. Yassi, H.L. Yeh, J.H. Yeh, S.J. Yeh, C.H. Yen, D. Young, C.L. Ysai, W.W. Zhang, H. Zhao, L. Zhao, Katharina Althaus-Knaurer, Jörg Berrouschot, Erich Bluhmki, Paolo Bovi, Gilles Chatellier, Lynda Cove, Stephen Davis, A. Dixit, Geoffrey Donnan, Christina Ehrenkrona, Christoph Eschenfelder, Marc Fatar, Juan Francisco Arenillas, Franz Gruber, Lalit Kala, Peter Kapeller, Markku Kaste, Christof Kessler, Martin Köhrmann, Rico Laage, Kennedy R. Lees, Alain Luna Rodriguez, Jean-Louis Mas, Robert Mikulik, Carlos Molina, Girish Muddegowda, Keith Muir, Kurt Niederkorn, Xavier Nuñez, Peter Schellinger, Joaquin Serena, Jan Sobesky, Thorsten Steiner, Ann-Sofie Svenson, Rüdiger von Kummer, Joanna Wardlaw, Rebecca A. Betensky, Gregoire Boulouis, Raphael A. Carandang, William A. Copen, Pedro Cougo, Shawna Cutting, Kendra Drake, Andria L. Ford, John Hallenbeck, Gordon J. Harris, Robert Hoesch, Amie Hsia, Carlos Kase, Lawrence Latour, Michael H. Lev, Alona Muzikansky, Nandakumar Nagaraja, Lee H. Schwamm, Eric Searls, Shlee S. Song, Sidney Starkman, Albert J. Yoo, Ramin Zand, Universitaetsklinikum Hamburg-Eppendorf = University Medical Center Hamburg-Eppendorf [Hamburg] (UKE), Hospices Civils de Lyon (HCL), Laboratoire de Biométrie et Biologie Evolutive - UMR 5558 (LBBE), Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Institut National de Recherche en Informatique et en Automatique (Inria)-VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Centre National de la Recherche Scientifique (CNRS), Université de Lyon, Monash University [Melbourne], National Cerebral and Cardiovascular Center (NCCC - OSAKA), Osaka University [Osaka], University of Heidelberg, Medical Faculty, Massachusetts General Hospital [Boston], University of Melbourne, Charité - UniversitätsMedizin = Charité - University Hospital [Berlin], Royal Adelaide Hospital [Adelaide Australia], National Institute of Neurological Disorders and Stroke [Bethesda] (NINDS), National Institutes of Health [Bethesda] (NIH), University Hospitals Leuven [Leuven], Catholic University of Leuven - Katholieke Universiteit Leuven (KU Leuven), Flanders Make [Leuven], Flanders Make, University of Newcastle [Australia] (UoN), Troubles cognitifs dégénératifs et vasculaires - U 1171 (TCDV), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Vall d'Hebron University Hospital [Barcelona], University of Glasgow, Cardiovasculaire, métabolisme, diabétologie et nutrition (CarMeN), Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)-Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Institut National des Sciences Appliquées de Lyon (INSA Lyon), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Hospices Civils de Lyon (HCL), Girona Biomedical Research Institute [Girona, Spain] (IDIBGI), Ruhr-Universität Bochum [Bochum], Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Aarhus University Hospital, Cedars-Sinai Medical Center, Florey Institute of Neuroscience and Mental Health [Melbourne, Victoria, Australia], Austin Health, Università degli Studi di Roma 'La Sapienza' = Sapienza University [Rome], China Medical University Hospital [Taichung], Karolinska Institutet [Stockholm], The Walter and Eliza Hall Institute of Medical Research (WEHI), University of Texas at Austin [Austin], Collaborators Evaluation of unknown Onset Stroke thrombolysis trials (EOS) investigators: Boris Raul Acosta, Karen Aegidius, Christian Albiker, Anna Alegiani, Miriam Almendrote, Angelika Alonso, Katharina Althaus, Pierre Amarenco, Hemasse Amiri, Bettina Anders, Adriana Aniculaesei, Jason Appleton, Juan Arenillas, Christina Back, Christian Bähr, Jürgen Bardutzky, Flore Baronnet-Chauvet, Rouven Bathe-Peters, Anna Bayer-Karpinska, Juan L Becerra, Christoph Beck, Olga Belchí Guillamon, Amandine Benoit, Nadia Berhoune, Daniela Bindila, Julia Birchenall, Karine Blanc-Lasserre, Miguel Blanco Gonzales, Tobias Bobinger, Ulf Bodechtel, Eric Bodiguel, Urszula Bojaryn, Louise Bonnet, Benjamin Bouamra, Paul Bourgeois, Florent Boutitie, Lorenz Breuer, Ludovic Breynaert, David Broughton, Raf Brouns, Sébastian Brugirard, Bart Bruneel, Florian Buggle, Serkan Cakmak, Ana Calleja, David Calvet, David Carrera, Hsin-Chieh Chen, Bastian Cheng, Bharath Cheripelli, Tae-Hee Cho, Chi-Un Choe, Lillian Choy, Hanne Christensen, Mareva Ciatipis, Geoffrey Cloud, Julien Cogez, Elisa Cortijo, Sophie Crozier, Dorte Damgaard, Krishna Dani, Beatrijs De Coene, Isabel De Hollander, Jacques De Keyser, Nina De Klippel, Charlotte De Maeseneire, Ann De Smedt, Maria Del Mar Castellanos Rodrigo, Sandrine Deltour, Jelle Demeestere, Laurent Derex, Philippe Desfontaines, Ralf Dittrich, Anand Dixit, Laurens Dobbels, Valérie Domigo, Laura Dorado, Charlotte Druart, Kristina Hougaard Dupont, Anne Dusart, Rainer Dziewas, Martin Ebinger, Matthias Ebner, Myriam Edjali-Goujon, Philipp Eisele, Salwa El Tawil, Ahmed Elhfnawy, Matthias Endres, Ana Etexberria, Nicholas Evans, Simon Fandler, Franz Fazekas, Sandra Felix, Jochen B Fiebach, Jens Fiehler, Alexandra Filipov, Katharina Filipski, Robert Fleischmann, Christian Foerch, Ian Ford, Alexandra Gaenslen, Ivana Galinovic, Elena Meseguer Gancedo, Ramanan Ganeshan, Carlos García Esperón, Alicia Garrido, Thomas Gattringer, Olivia Geraghty, Rohat Geran, Christian Gerloff, Stefan Gerner, Sylvie Godon-Hardy, Jos Göhler, Amir Golsari, Meritxell Gomis, David Gorriz, Verena Gramse, Laia Grau, Martin Griebe, Cristina Guerrero, Damla Guerzoglu, Sophie Guettier, Vincent Guiraud, Christoph Gumbinger, Ignaz Gunreben, Florian Haertig, Christian Hametner, Bernard Hanseeuw, Andreas Hansen, Jakob Hansen, Thomas Harbo, Andreas Harloff, Peter Harmel, Karl Georg Häusler, Florian Heinen, Valentin Held, Simon Hellwig, Dimitri Hemelsoet, Michael Hennerici, Juliane Herm, Sylvia Hermans, María Hernández, Jose Hervas Vicente, Niels Hjort, Cristina Hobeanu, Carsten Hobohm, Elmar Höfner, Katharina Hohenbichler, Marc Hommel, Julia Hoppe, Eva Hornberger, Carolin Hoyer, Xuya Huang, Nils Ipsen, Irina Isern, Lourdes Ispierto, Helle Iversen, Lise Jeppesen, Marta Jimenez, Jan Jungehülsing, Eric Jüttler, Dheeraj Kalladka, Bernd Kallmünzer, Arindam Kar, Lars Kellert, André Kemmling, Tobias Kessler, Usman Khan, Matthias Klein, Christoph Kleinschnitz, Matti Klockziem, Michael Knops, Luzie Koehler, Martin Koehrmann, Heinz Kohlfürst, Rainer Kollmar, Peter Kraft, Thomas Krause, Bo Kristensen, Jan M Kröber, Natalia Kurka, Alexandre Ladoux, Patrice Laloux, Catherine Lamy, Emmanuelle Landrault, Arne Lauer, Claire Lebely, Jonathan Leempoel, Kennedy Lees, Anne Leger, Laurence Legrand, Robin Lemmens, Lin Li, Anna-Mareike Löbbe, Frederic London, Elena Lopez-Cancio, Matthias Lorenz, Stephen Louw, Caroline Lovelock, Manuel Lozano Sánchez, Giuseppe Lucente, Janos Lückl, Alain Luna, Kosmas Macha, Alexandre Machet, Daniel Mackenrodt, Dominik Madzar, Charles Majoie, Anika Männer, Vicky Maqueda, Jacob Marstrand, Alicia Martinez, Annika Marzina, Laura Mechthouff, Per Meden, Guy Meersman, Julia Meier, Charles Mellerio, Oliver Menn, Nadja Meyer, Dominik Michalski, Peter Michels, Lene Michelsen, Monica Millán Torne, Jens Minnerup, Boris Modrau, Sebastian Moeller, Anette Møller, Nathalie Morel, Fiona Moreton, Ludovic Morin, Thierry Moulin, Barry Moynihan, Anne K Mueller, Keith W Muir, Patricia Mulero, Sibu Mundiyanapurath, Johannes Mutzenbach, Simon Nagel, Oliver Naggara, Arumugam Nallasivan, Irene Navalpotro, Alexander H Nave, Paul Nederkoorn, Lars Neeb, Hermann Neugebauer, Tobias Neumann-Haefelin, Norbert Nighoghossian, Stefan Oberndorfer, Christian Opherk, Lorenz Oppel, Catherine Oppenheim, Johannes Orthgieß, Leif Ostergaard, Perrine Paindeville, Ernest Palomeras, Verena Panitz, Bhavni Patel, Andre Peeters, Dirk Peeters, Anna Pellisé, Johann Pelz, Anthony Pereira, Natalia Pérez de la Ossa, Richard Perry, Salvador Petraza, Stéphane Peysson, Waltraud Pfeilschifter, Alexander Pichler, Alexandra Pierskalla, Hans-Werner Pledl, Sven Poli, Katrin Pomrehn, Marika Poulsen, Luis Prats, Silvia Presas, Elisabeth Prohaska, Volker Puetz, Josep Puig, Josep Puig Alcántara, Jan Purrucker, Veronique Quenardelle, Sankaranarayanan Ramachandran, Soulliard Raphaelle, Nicolas Raposo, Tilman Reiff, Michel Remmers, Pauline Renou, Martin Ribitsch, Hardy Richter, Peter Ringleb, Martin Ritter, Thomas Ritzenthaler, Gilles Rodier, Christine Rodriguez-Regent, Manuel Rodríguez-Yáñez, Maria Roennefarth, Christine Roffe, Sverre Rosenbaum, Charlotte Rosso, Joachim Röther, Michal Rozanski, Noelia Ruiz de Morales, Francesca Russo, Matthieu Rutgers, Sharmilla Sagnier, Yves Samson, Josep Sánchez, Tamara Sauer, Jan H Schäfer, Simon Schieber, Josef Schill, Dennis Schlak, Ludwig Schlemm, Sein Schmidt, Wouter Schonewille, Julian Schröder, Andreas Schulz, Johannes Schurig, Sönke Schwarting, Alexander Schwarz, Christopher Schwarzbach, Matthias Seidel, Alexander Seiler, Jochen Sembill, Joaquin Serena Leal, Ashit Shetty, Igor Sibon, Claus Z Simonsen, Oliver Singer, Aravinth Sivagnanaratham, Ide Smets, Craig Smith, Peter Soors, Nikola Sprigg, Maximilian Spruegel, David Stark, Susanne Steinert, Sebastian Stösser, Markus Stuermlinger, Bart Swinnen, Ruben Tamazyan, Jose Tembl, Mikel Terceno Izaga, Vincent Thijs, Götz Thomalla, Emmanuel Touze, Thomas Truelsen, Guillaume Turc, Gaetane Turine, Serdar Tütüncü, Pippa Tyrell, Xavier Ustrell, Wilfried Vadot, Anne-Evelyne Vallet, Pauline Vallet, Lucie van den Berg, Sophie van den Berg, Cecile van Eendenburg, Robbert-Jan Van Hooff, Isabelle van Sloten, Peter Vanacker, Evelien Vancaester, Patrick Vanderdonckt, Yves Vandermeeren, Frederik Vanhee, Roland Veltkamp, Karsten Vestergaard, Alain Viguier, Dolores Vilas, Kersten Villringer, Dieke Voget, Jörg von Schrader, Paul von Weitzel, Elisabeth Warburton, Claudia Weber, Jörg Weber, Karl Wegscheider, Mirko Wegscheider, Christian Weimar, Karin Weinstich, Christopher Weise, Gesa Weise, Chris Willems, Klemens Winder, Matthias Wittayer, Marc Wolf, Martin Wolf, Valerie Wolff, Christian Wollboldt, Frank Wollenweber, Anke Wouters, Bertrand Yalo, Marion Yger, Nadia Younan, Laetita Yperzeele, Vesna Zegarac, Pia Zeiner, Ulf Ziemann, Thomas Zonneveld, Mathieu Zuber, Tsugio Akutsu, Junya Aoki, Junya Aoki, Shuji Arakawa, Ryosuke Doijiri, Yusuke Egashira, Yukiko Enomoto, Mayumi Fukuda-Doi, Eisuke Furui, Konosuke Furuta, Seiji Gotoh, Toshimitsu Hamasaki, Yasuhiro Hasegawa, Teryuki Hirano, Kazunari Homma, Masahiko Ichijyo, Toshihiro Ide, Shuichi Igarashi, Yasuyuki Iguchi, Masafumi Ihara, Hajime Ikenouchi, Manabu Inoue, Tsuyoshi Inoue, Ryo Itabashi, Yasuhiro Ito, Toru Iwama, Kenji Kamiyama, Shoko Kamiyoshi, Haruka Kanai, Yasuhisa Kanematsu, Takao Kanzawa, Kazumi Kimura, Jiro Kitayama, Takanari Kitazono, Masatoshi Koga, Rei Kondo, Kohsuke Kudo, Masayoshi Kusumi, Ken Kuwahara, Shoji Matsumoto, Hideki Matsuoka, Ban Mihara, Kazuo Minematsu, Ken Miura, Kaori Miwa, Naomi Morita, Wataru Mouri, Kayo Murata, Yoshinari Nagakane, Taizen Nakase, Hiromi Ohara, Nobuyuki Ohara, Hideyuki Ohnishi, Hajime Ohta, Masafumi Ohtaki, Ryo Ohtani, Toshiho Ohtsuki, Hideo Ohyama, Takashi Okada, Yasushi Okada, Masato Osaki, Nobuyuki Sakai, Yoshiki Sanbongi, Naoshi Sasaki, Makoto Sasaki, Shoichiro Sato, Kenta Seki, Wataru Shimizu, Yoshiaki Shiokawa, Takashi Sozu, Junichiro Suzuki, Rieko Suzuki, Yasushi Takagi, Shunya Takizawa, Norio Tanahashi, Eijiro Tanaka, Ryota Tanaka, Yohei Tateishi, Tomoaki Terada, Tadashi Terasaki, Kenichi Todo, Azusa Tokunaga, Kazunori Toyoda, Akira Tsujino, Toshihiro Ueda, Yoshikazu Uesaka, Mihoko Uotani, Takao Urabe, Masao Watanabe, Yoshiki Yagita, Yusuke Yakushiji, Haruko Yamamoto, Keizo Yasui, Toshiro Yonehara, Sohei Yoshimura, Shinichi Yoshimura, K Aarnio, F Alemseged, C Anderson, T Ang, M L Archer, J Attia, P Bailey, A Balabanski, A Barber, P A Barber, J Bernhardt, A Bivard, D Blacker, C F Bladin, A Brodtmann, D Cadilhac, B C V Campbell, L Carey, S Celestino, L Chan, W H Chang, A ChangI, C H Chen, C-I Chen, H F Chen, T C Chen, W H Chen, Y Y Chen, C A Cheng, E Cheong, Y W Chiou, P M Choi, H J Chu, C S Chuang, T C Chung, L Churilov, B Clissold, A Connelly, S Coote, B Coulton, E Cowley, J Cranefield, S Curtze, C D'Este, S M Davis, S Day, P M Desmond, H M Dewey, C Ding, G A Donnan, R Drew, S Eirola, D Field, T Frost, C Garcia-Esperon, K George, R Gerraty, R Grimley, Y C Guo, G Hankey, J Harvey, S C Ho, K Hogan, D Howells, P M Hsiao, C H Hsu, C T Hsu, C-S Hsu, J P Hsu, Y D Hsu, Y T Hsu, C J Hu, C C Huang, H Y Huang, M Y Huang, S C Huang, W S Huang, D Jackson, J S Jeng, S K Jiang, L Kaauwai, O Kasari, J King, T J Kleinig, M Koivu, J Kolbe, M Krause, C W Kuan, W L Kung, C Kyndt, C L Lau, A Lee, C Y Lee, J T Lee, Y Lee, Y C Lee, C Levi, C R Levi, L M Lien, J C Lim, C C Lin, C H Lin, C M Lin, D Lin, C H Liu, J Liu, Y C Lo, P S Loh, E Low, C H Lu, C J Lu, M K Lu, J Ly, H Ma, L Macaulay, R Macdonnell, E Mackey, M Macleod, J Mahadevan, V Maxwell, R McCoy, A McDonald, S McModie, A Meretoja, S Mishra, P J Mitchell, F Miteff, A Moore, C Muller, F Ng, F C Ng, J-L Ng, W O'Brian, V O'Collins, T J Oxley, M W Parsons, S Patel, G S Peng, L Pesavento, T Phan, E Rodrigues, Z Ross, A Sabet, M Sallaberger, P Salvaris, D Shah, G Sharma, G Sibolt, M Simpson, S Singhal, B Snow, N Spratt, R Stark, J Sturm, M C Sun, Y Sun, P S Sung, Y F Sung, M Suzuki, M Tan, S C Tang, T Tatlisumak, V Thijs, M Tiainen, C H Tsai, C K Tsai, C L Tsai, H T Tsai, L K Tsai, C H Tseng, L T Tseng, J Tsoleridis, H Tu, H T-H Tu, W Vallat, J Virta, W C Wang, Y T Wang, M Waters, L Weir, T Wijeratne, C Williams, W Wilson, A A Wong, K Wong, T Y Wu, Y H Wu, B Yan, F C Yang, Y W Yang, N Yassi, H L Yeh, J H Yeh, S J Yeh, C H Yen, D Young, C L Ysai, W W Zhang, H Zhao, L Zhao, Katharina Althaus-Knaurer, Martin Bendszus, Jörg Berrouschot, Erich Bluhmki, Paolo Bovi, Gilles Chatellier, Lynda Cove, Stephen Davis, A Dixit, Geoffrey Donnan, Rainer Dziewas, Christina Ehrenkrona, Christoph Eschenfelder, Marc Fatar, Juan Francisco Arenillas, Franz Gruber, Werner Hacke, Lalit Kala, Peter Kapeller, Markku Kaste, Christof Kessler, Martin Köhrmann, Rico Laage, Kennedy R Lees, Didier Leys, Alain Luna Rodriguez, Jean-Louis Mas, Robert Mikulik, Carlos Molina, Girish Muddegowda, Keith Muir, Kurt Niederkorn, Xavier Nuñez, Catherine Oppenheim, Sven Poli, Peter Ringleb, Peter Schellinger, Stefan Schwab, Joaquin Serena, Jan Sobesky, Thorsten Steiner, Ann-Sofie Svenson, Danilo Toni, Roland Veltkamp, Rüdiger von Kummer, Nils Wahlgren, Joanna Wardlaw, Rebecca A Betensky, Gregoire Boulouis, Raphael A Carandang, William A Copen, Pedro Cougo, Shawna Cutting, Kendra Drake, Andria L Ford, John Hallenbeck, Gordon J Harris, Robert Hoesch, Amie Hsia, Carlos Kase, Lawrence Latour, Arne Lauer, Michael H Lev, Alona Muzikansky, Nandakumar Nagaraja, Lee H Schwamm, Eric Searls, Shlee S Song, Sidney Starkman, Steven Warach, Ona Wu, Albert J Yoo, Ramin Zand, University of Newcastle [Callaghan, Australia] (UoN), Université de Lyon-Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Hospices Civils de Lyon (HCL)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Università degli Studi di Roma 'La Sapienza' = Sapienza University [Rome] (UNIROMA), Troubles cognitifs dégénératifs et vasculaires - U 1171 - EA 1046 (TCDV), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lille, Droit et Santé-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), CarMeN, laboratoire, Yperzeele, Laetitia, Evaluation of Unknown Onset Stroke Thrombolysis trials (EOS) investigators, UCL - SSS/IONS - Institute of NeuroScience, UCL - (MGD) Service de neurologie, Supporting clinical sciences, UZB Other, Physical Medicine and Rehabilitation, Clinical sciences, Neuroprotection & Neuromodulation, Radiology and Nuclear Medicine, ANS - Neurovascular Disorders, Neurology, ACS - Atherosclerosis & ischemic syndromes, Graduate School, Center of Experimental and Molecular Medicine, ACS - Pulmonary hypertension & thrombosis, and ACS - Microcirculation

Subjects
medicine.medical_treatment, [SDV]Life Sciences [q-bio], Ischemic Stroke/*diagnostic imaging/*drug therapy, Tomography, X-Ray Computed/methods, Fibrinolytic Agents/adverse effects/*therapeutic use, 030204 cardiovascular system & hematology, Ischemic Stroke/diagnostic imaging, surgery, 0302 clinical medicine, Modified Rankin Scale, 030212 general & internal medicine, 10. No inequality, Infusions, Intravenous, Stroke, Tomography, Time-to-Treatment, General Medicine, Thrombolysis, X-Ray Computed/methods, Tissue Plasminogen Activator/adverse effects, 3. Good health, [SDV] Life Sciences [q-bio], Diffusion Magnetic Resonance Imaging/methods, Treatment Outcome, Meta-analysis, Tissue Plasminogen Activator, Intravenous, medicine.medical_specialty, Infusions, Intravenous thrombolysis, Neuroimaging, Neuroscience(all), Placebo, Tissue Plasminogen Activator/adverse effects/*therapeutic use, 03 medical and health sciences, Fibrinolytic Agents, Internal medicine, medicine, Humans, ddc:610, Ischemic Stroke, business.industry, neurology, Fibrinolytic Agents/adverse effects, Odds ratio, Recovery of Function, medicine.disease, Clinical research, Diffusion Magnetic Resonance Imaging, Human medicine, business, Tomography, X-Ray Computed, Fibrinolytic agent
Abstract

International audience; BACKGROUND: Patients who have had a stroke with unknown time of onset have been previously excluded from thrombolysis. We aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers. METHODS: We did a systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020. Randomised trials of intravenous alteplase versus standard of care or placebo in adults with stroke with unknown time of onset with perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch were eligible. The primary outcome was favourable functional outcome (score of 0-1 on the modified Rankin Scale [mRS]) at 90 days indicating no disability using an unconditional mixed-effect logistic-regression model fitted to estimate the treatment effect. Secondary outcomes were mRS shift towards a better functional outcome and independent outcome (mRS 0-2) at 90 days. Safety outcomes included death, severe disability or death (mRS score 4-6), and symptomatic intracranial haemorrhage. This study is registered with PROSPERO, CRD42020166903. FINDINGS: Of 249 identified abstracts, four trials met our eligibility criteria for inclusion: WAKE-UP, EXTEND, THAWS, and ECASS-4. The four trials provided individual patient data for 843 individuals, of whom 429 (51%) were assigned to alteplase and 414 (49%) to placebo or standard care. A favourable outcome occurred in 199 (47%) of 420 patients with alteplase and in 160 (39%) of 409 patients among controls (adjusted odds ratio [OR] 1·49 [95% CI 1·10-2·03]; p=0·011), with low heterogeneity across studies (I(2)=27%). Alteplase was associated with a significant shift towards better functional outcome (adjusted common OR 1·38 [95% CI 1·05-1·80]; p=0·019), and a higher odds of independent outcome (adjusted OR 1·50 [1·06-2·12]; p=0·022). In the alteplase group, 90 (21%) patients were severely disabled or died (mRS score 4-6), compared with 102 (25%) patients in the control group (adjusted OR 0·76 [0·52-1·11]; p=0·15). 27 (6%) patients died in the alteplase group and 14 (3%) patients died among controls (adjusted OR 2·06 [1·03-4·09]; p=0·040). The prevalence of symptomatic intracranial haemorrhage was higher in the alteplase group than among controls (11 [3%] vs two [\textless1%], adjusted OR 5·58 [1·22-25·50]; p=0·024). INTERPRETATION: In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death. FUNDING: None.

Published
2020
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22. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

Author

Ana Catarina Fonseca, Guillaume Turc, Natalia Pérez de la Ossa, Daniel Strbian, Gian Marco De Marchis, William Whiteley, Eivind Berge, Heinrich J. Audebert, Chiara Padiglioni, Georgios Tsivgoulis, Oslo University Hospital [Oslo], University of Edinburgh, Charité - UniversitätsMedizin = Charité - University Hospital [Berlin], University of Basel (Unibas), Universidade de Lisboa = University of Lisbon (ULISBOA), USL Umbria 1 [Perugia, Italy] (Azienda USL Umbria 1), Germans Trias i Pujol University Hospital [Badalona, Barcelona, Spain] (GTPUH), Helsingin yliopisto = Helsingfors universitet = University of Helsinki, National and Kapodistrian University of Athens (NKUA), The University of Tennessee Health Science Center [Memphis] (UTHSC), Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), FHU NeuroVasc [Site Sainte-Anne, Paris] (GHU-PPN), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Cité (UPCité), Martinez Rico, Clara, Universidade de Lisboa (ULISBOA), Germans Trias i Pujol University Hospital [Badalona, Spain], University of Helsinki, Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université de Paris (UP), Neurologian yksikkö, HUS Neurocenter, Helsinki University Hospital Area, and Repositório da Universidade de Lisboa

Subjects
medicine.medical_specialty, thrombolysis, medicine.medical_treatment, 030204 cardiovascular system & hematology, Guideline, 3124 Neurology and psychiatry, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Ischaemic stroke, Fibrinolysis, medicine, Stroke, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, business.industry, 3112 Neurosciences, Thrombolysis, medicine.disease, 3. Good health, thrombectomy, recommendations, Cardiology, fibrinolysis, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

© European Stroke Organisation 2021, Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.

Published
2021
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23. Endovascular reperfusion of M2 occlusions in acute ischemic stroke reduced disability and mortality: ETIS Registry results

Author

Bertrand Lapergue, Gaultier Marnat, Maxime Gauberti, Arturo Consoli, Stephane Vannier, François Eugène, Romain Bourcier, Frédéric Bourdain, Suzana Saleme, Caroline Arquizan, Marion Boulanger, Sébastien Richard, Louis Veunac, Ozlem Ozkul-Wermester, Anthony Le Bras, Benjamin Gory, Cyril Dargazanli, Jean-Christophe Gentric, Stephanos Nikolaos Finitsis, Mohammad Anadani, C. Papagiannaki, Valérie Wolff, Christophe Cognard, Benjamin Maïer, Laurent Spelle, Christian Denier, Patricio Muszynski, Sarah Evain, Francisco Macian, Guillaume Turc, Raoul Pop, Raphaël Blanc, Frédéric Clarençon, Alain Viguier, Serge Timsit, Olivier Naggara, Igor Sibon, and Charlotte Rosso

Subjects
medicine.medical_specialty, medicine.medical_treatment, Brain Ischemia, Modified Rankin Scale, Internal medicine, medicine, Humans, Favorable outcome, Prospective Studies, Registries, Endovascular treatment, Stroke, Acute ischemic stroke, Ischemic Stroke, Thrombectomy, business.industry, Cerebral infarction, Stroke scale, Endovascular Procedures, General Medicine, Thrombolysis, medicine.disease, Treatment Outcome, Reperfusion, Cardiology, Surgery, Neurology (clinical), business
Abstract

BackgroundThe predictors of successful reperfusion and the effect of reperfusion after endovascular treatment (EVT) for M2 occlusions have not been well studied. We aimed to identify predictors of successful reperfusion and the effect of reperfusion on outcomes of EVT for M2 occlusions in current practice.MethodsPatients with acute ischemic stroke due to isolated M2 occlusions who were enrolled in the prospective multicenter Endovascular Treatment in Ischemic Stroke (ETIS) Registry in France between January 2015 and March 2020 were included. The primary outcome was a favorable outcome, defined as modified Rankin Scale (mRS) score of 0–2 at 90 days. Successful reperfusion was defined as an improvement of ≥1 points in the modified Thrombolysis In Cerebral Infarction score between the first and the last intracranial angiogram.ResultsA total of 458 patients were included (median National Institutes of Health Stroke Scale (NIHSS) score 14; 61.4% received prior intravenous thrombolysis). Compared with the non-reperfused patients, reperfused patients had an increased rate of excellent outcome (OR 2.3, 95% CI 0.98 to 5.36; p=0.053), favorable outcome (OR 2.79, 95% CI 1.31 to 5.93; p=0.007), and reduced 90-day mortality (OR 0.39, 95% CI 0.19 to 0.79; pConclusionsSuccessful reperfusion of M2 occlusions reduced disability and mortality. However, safety is a concern, especially if the procedure failed.

Published
2021

24. The Impact of SARS‐CoV ‐2 on Stroke Epidemiology and Care: A Meta‐Analysis

Author

Shima Shahjouei, Sotirios Tsiodras, Shadi Yaghi, Konstantinos Tsioufis, Georgios Tsivgoulis, Lina Palaiodimou, Vivek Sharma, Dimitris Mavridis, Andrei V Alexandrov, Guillaume Turc, Ramin Zand, Luciana Catanese, Babak B. Navi, Ashkan Shoamanesh, Aristeidis H. Katsanos, Hooman Kamel, Michele Romoli, Konstantinos Vadikolias, Pagona Lagiou, Population Health Research Institute [Hamilton, ON, Canada], National and Kapodistrian University of Athens (NKUA), Geisinger Health System [Danville, PA, USA], New York University Langone Medical Center (NYU Langone Medical Center), NYU System (NYU), Weill Cornell Medicine [New York], Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), FHU NeuroVasc [Site Sainte-Anne, Paris] (GHU-PPN), Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université de Paris (UP), Maurizio Bufalini Hospital [Cesena, Italy], Università degli Studi di Perugia (UNIPG), National University of Singapore (NUS), University of Ioannina, Université Paris Descartes - Faculté de Médecine (UPD5 Médecine), Université Paris Descartes - Paris 5 (UPD5), Democritus University of Thrace (DUTH), Harvard T.H. Chan School of Public Health, The University of Tennessee Health Science Center [Memphis] (UTHSC), National School of Public Health [Athens], Martinez Rico, Clara, Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Cité (UPCité), and Università degli Studi di Perugia = University of Perugia (UNIPG)

Subjects
0301 basic medicine, medicine.medical_specialty, Clinical Neurology, Disease, Comorbidity, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Epidemiology, medicine, Diabetes Mellitus, Humans, Thrombolytic Therapy, [SDV.NEU] Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Hospital Mortality, Stroke, Research Articles, Thrombectomy, business.industry, SARS-CoV-2, Case-control study, COVID-19, Odds ratio, medicine.disease, 3. Good health, 030104 developmental biology, Neurology, Meta-analysis, Case-Control Studies, [SDV.NEU]Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Neurology (clinical), business, 030217 neurology & neurosurgery, Cohort study, Research Article
Abstract

International audience; Objective: Emerging data indicate an increased risk of cerebrovascular events with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and highlight the potential impact of coronavirus disease (COVID-19) on the management and outcomes of acute stroke. We conducted a systematic review and meta-analysis to evaluate the aforementioned considerations.Methods: We performed a meta-analysis of observational cohort studies reporting on the occurrence and/or outcomes of patients with cerebrovascular events in association with their SARS-CoV-2 infection status. We used a random-effects model. Summary estimates were reported as odds ratios (ORs) and corresponding 95% confidence intervals (CIs).Results: We identified 18 cohort studies including 67,845 patients. Among patients with SARS-CoV-2, 1.3% (95% CI = 0.9-1.6%, I2 = 87%) were hospitalized for cerebrovascular events, 1.1% (95% CI = 0.8-1.3%, I2 = 85%) for ischemic stroke, and 0.2% (95% CI = 0.1-0.3%, I2 = 64%) for hemorrhagic stroke. Compared to noninfected contemporary or historical controls, patients with SARS-CoV-2 infection had increased odds of ischemic stroke (OR = 3.58, 95% CI = 1.43-8.92, I2 = 43%) and cryptogenic stroke (OR = 3.98, 95% CI = 1.62-9.77, I2 = 0%). Diabetes mellitus was found to be more prevalent among SARS-CoV-2 stroke patients compared to noninfected historical controls (OR = 1.39, 95% CI = 1.00-1.94, I2 = 0%). SARS-CoV-2 infection status was not associated with the likelihood of receiving intravenous thrombolysis (OR = 1.42, 95% CI = 0.65-3.10, I2 = 0%) or endovascular thrombectomy (OR = 0.78, 95% CI = 0.35-1.74, I2 = 0%) among hospitalized ischemic stroke patients during the COVID-19 pandemic. Odds of in-hospital mortality were higher among SARS-CoV-2 stroke patients compared to noninfected contemporary or historical stroke patients (OR = 5.60, 95% CI = 3.19-9.80, I2 = 45%).Interpretation: SARS-CoV-2 appears to be associated with an increased risk of ischemic stroke, and potentially cryptogenic stroke in particular. It may also be related to an increased mortality risk. ANN NEUROL 2021;89:380-388.

Published
2021
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25. Endovascular treatment for basilar artery occlusion: A systematic review and meta-analysis

Author

Adam S Arthur, Andrei V. Alexandrov, Marios Psychogios, Amrou Sarraj, Luciana Catanese, Guy Raphaeli, Stavros Nikolakopoulos, Dimitris Mavridis, Evangelia Kararizou, Marios Themistocleous, Nitin Goyal, Brian van Adel, Christos Krogias, Georgios Magoufis, Guillaume Turc, Apostolos Safouris, Georgios Tsivgoulis, and Aristeidis H. Katsanos

Subjects
medicine.medical_specialty, 03 medical and health sciences, 0302 clinical medicine, Modified Rankin Scale, Internal medicine, Medicine, Humans, Thrombolytic Therapy, 030212 general & internal medicine, Endovascular treatment, Thrombectomy, business.industry, Endovascular Procedures, Odds ratio, Confidence interval, Clinical trial, Stroke, Treatment Outcome, Neurology, Meta-analysis, Relative risk, Basilar Artery, Observational study, Neurology (clinical), business, 030217 neurology & neurosurgery
Abstract

Background and purpose Independent randomized controlled clinical trials (RCTs) have provided robust evidence for endovascular treatment (EVT) as the standard of care treatment for acute large vessel occlusions in the anterior circulation. We examined available studies specific to posterior cerebral circulation ischemic strokes to see if any conclusions can be drawn regarding EVT options. Methods We performed a systematic literature search to identify studies evaluating the safety and efficacy of EVT versus standard medical treatment for patients with acute basilar artery occlusion (BAO). We extracted data for outcomes of interest and presented associations between the two groups with the use of risk ratios (RRs) or odds ratios (ORs), with corresponding 95% confidence intervals (CIs). We used a random-effects model to pool the effect estimates. Results We identified five studies (two RCTs, three observational cohorts) including a total of 1098 patients. Patients receiving EVT had a higher risk of symptomatic intracranial hemorrhage (sICH) compared to those receiving non-interventional medical management (RR 5.42, 95% CI 2.74-10.71). Nonsignificant trends towards modified Rankin Scale (mRS) scores 0-2 (RR 1.02, 95% CI 0.74-1.41), mRS scores 0-3 (RR = 0.97, 95% CI 0.64-1.47), overall functional improvement (OR 0.93, 95% CI 0.57-1.51), and all-cause mortality (RR 1.03, 95% CI 0.78-1.35) at 3 months were seen. Conclusion Although EVT increases the probability of sICH, the available data do not exclude the possibility of improved functional outcomes over standard therapy. As larger studies are challenged by the perceived lack of equipoise in this vulnerable patient population, results of ongoing RCTs are expected to provide substantial input for future meta-analyses.

Published
2021

26. Intended Bridging Therapy or Intravenous Thrombolysis Alone in Minor Stroke With Basilar Artery Occlusion

Author

Laurent Suissa, Philippe Niclot, Denis Sablot, Bertrand Lapergue, Gioia Mione, Aude Triquenot, Isabelle Girard-Buttaz, Nadia Laksiri, Cyril Dargazanli, Michael Obadia, Cécile Preterre, Aïcha Lyoubi, Igor Sibon, Pierre Seners, Séverine Debiais, Duc-Long Duong, Caroline Arquizan, Guillaume Turc, Jean-Claude Baron, Jérémie Papassin, C. Lamy, Hilde Hénon, Pierre Garnier, Claire Perrin, Michel Piotin, Jean-Louis Mas, Serge Bracard, RANCHON, GUILLAUME, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), FHU NeuroVasc [Site Sainte-Anne, Paris] (GHU-PPN), Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Cité (UPCité), Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Fondation Ophtalmologique Adolphe de Rothschild [Paris], Centre Hospitalier Saint Jean de Perpignan, Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Centre Hospitalier René Dubos [Pontoise], and MINOR-STROKE Collaborators: Claire Perrin, Caroline Arquizan, Chantal Lamy, Igor Sibon, Michael Obadia, Jérémie Papassin, Hilde Henon, Cécile Preterre, Laurent Suissa, Séverine Debiais, Aïcha Lyoubi, Pierre Garnier, Isabelle Girard-Buttaz, Bertrand Lapergue, Aude Triquenot, Duc-Long Duong, Nadia Laksiri, Gioia Mione, Jean-Louis Mas

Subjects
Male, medicine.medical_specialty, Bridging (networking), [SDV]Life Sciences [q-bio], medicine.medical_treatment, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, medicine.artery, Internal medicine, Fibrinolysis, ischemic stroke, Basilar artery, medicine, Vertebrobasilar Insufficiency, Humans, basilar artery, Thrombolytic Therapy, Propensity Score, Aged, Retrospective Studies, Thrombectomy, Advanced and Specialized Nursing, Aged, 80 and over, business.industry, Basilar artery occlusion, Minor stroke, Thrombolysis, Middle Aged, Combined Modality Therapy, [SDV] Life Sciences [q-bio], Mechanical thrombectomy, Stroke, Treatment Outcome, Ischemic stroke, Cardiology, fibrinolysis, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery
Abstract

Background and Purpose: Whether bridging therapy (intravenous thrombolysis [IVT] followed by mechanical thrombectomy) is superior to IVT alone in minor stroke with basilar artery occlusion remains uncertain. Methods: Multicentric retrospective observational study of consecutive minor stroke patients (National Institutes of Health Stroke Scale score ≤5) with basilar artery occlusion intended for IVT alone or bridging therapy. Propensity-score weighting was used to reduce baseline between-groups differences, and residual imbalance was addressed through adjusted logistic regression, with excellent outcome (3-month modified Rankin Scale score 0–1) as the dependent variable. Results: Fifty-seven patients were included (28 and 29 in the bridging therapy and IVT alone groups, respectively). Following propensity-score weighting, the distribution of baseline clinical and radiological variables was similar across the 2 patient groups, except age, posterior circulation Alberta Stroke Program Early CT Score, history of hypertension and smoking, and onset-to-IVT time. Compared with IVT alone, bridging therapy was associated with excellent outcome (adjusted odds ratio=3.37 [95% CI, 1.13–10.03]; P =0.03). No patient experienced symptomatic intracranial hemorrhage. Conclusions: Our results suggest that bridging therapy may be superior to IVT alone in minor stroke with basilar artery occlusion.

Published
2021
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27. Relevance of Brain Regions' Eloquence Assessment in Patients With a Large Ischemic Core Treated With Mechanical Thrombectomy

Author

Basile, Kerleroux, Joseph, Benzakoun, Kévin, Janot, Cyril, Dargazanli, Dimitri Daly, Eraya, Wagih, Ben Hassen, François, Zhu, Benjamin, Gory, Jean-Francois, Hak, Charline, Perot, Lili, Detraz, Romain, Bourcier, Rouchaud, Aymeric, Géraud, Forestier, Gaultier, Marnat, Florent, Gariel, Pasquale, Mordasini, Pierre, Seners, Guillaume, Turc, Johannes, Kaesmacher, Catherine, Oppenheim, Olivier, Naggara, Gregoire, Boulouis, Jean Christophe, Labour, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), GHU Paris Psychiatrie et Neurosciences, Centre Hospitalier Régional Universitaire de Tours (CHRU TOURS), CHU Montpellier, Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Hôpital Gui de Chauliac [Montpellier], Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Hôpital de la Timone [CHU - APHM] (TIMONE), Aix Marseille Université (AMU), Hôpital Guillaume-et-René-Laennec [Saint-Herblain], Hôpital Dupuytren [CHU Limoges], Hôpital Pellegrin, CHU Bordeaux [Bordeaux]-Groupe hospitalier Pellegrin, University of Bern, Hôpital Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), FHU NeuroVasc [Site Sainte-Anne, Paris] (GHU-PPN), Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université de Paris (UP), Martinez Rico, Clara, Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Centre Hospitalier Régional Universitaire de Tours (CHRU Tours), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Cité (UPCité), Hôpital Gui de Chauliac [CHU Montpellier], CHU Rothschild [AP-HP], and Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)

Subjects
Male, medicine.medical_specialty, 610 Medicine & health, Brain tissue, 030204 cardiovascular system & hematology, Logistic regression, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Primary outcome, Internal medicine, medicine, Humans, Infarct core, In patient, [SDV.NEU] Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Aged, Ischemic Stroke, Retrospective Studies, Thrombectomy, Aged, 80 and over, Core (anatomy), [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, business.industry, Middle Aged, Magnetic Resonance Imaging, Mechanical thrombectomy, Treatment Outcome, Infarction, Cardiology, Female, [SDV.NEU]Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Neurology (clinical), business, 610 Medizin und Gesundheit, Perfusion, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, 030217 neurology & neurosurgery
Abstract

ObjectiveIndividualized patient selection for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) and large ischemic core (LIC) at baseline is an unmet need. We tested the hypothesis that assessing the functional relevance of both infarcted and hypoperfused brain tissue would improve the selection framework of patients with LIC for MT.MethodsWe performed a multicenter, retrospective study of adults with LIC (ischemic core volume >70 mL on MRI diffusion-weighted imaging) with MRI perfusion treated with MT or best medical management (BMM). Primary outcome was 3-month modified Rankin Scale (mRS), favorable if 0–3. Global and regional eloquence-based core perfusion mismatch ratios were derived. The predictive accuracy for clinical outcome of eloquent regions involvement was compared in multivariable and bootstrap random forest models.ResultsA total of 138 patients with baseline LIC were included (MT n = 96 or BMM n = 42; mean age ± SD, 72.4 ± 14.4 years; 34.1% female; mRS 0–3: 45.1%). Mean core and critically hypoperfused volume were 100.4 mL ± 36.3 mL and 157.6 ± 56.2 mL, respectively, and did not differ between groups. Models considering the functional relevance of the infarct location showed a better accuracy for the prediction of mRS 0–3 with a c statistic of 0.76 and 0.83 for logistic regression model and bootstrap random forest testing sets, respectively. In these models, the interaction between treatment effect of MT and the mismatch was significant (p = 0.04). In comparison, in the logistic regression model disregarding functional eloquence, the c statistic was 0.67 and the interaction between MT and the mismatch was insignificant.ConclusionsConsidering functional eloquence of hypoperfused tissue in patients with a large infarct core at baseline allows for a more precise estimation of treatment expected benefit.Classification of EvidenceThis study provides Class II evidence that, in patients with AIS and LIC, considering the functional eloquence of the infarct location improves prediction of disability status at 3 months.

Published
2021
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28. Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs

Author

Simona Sacco, Maria Ioanna Stefanou, Urs Fischer, Jens Fiehler, Andrei V. Alexandrov, Marios Psychogios, Georgios Tsivgoulis, Ashkan Shoamanesh, Daniel Strbian, Marios Themistocleous, Aristeidis H. Katsanos, Lina Palaiodimou, Johannes Kaesmacher, Jan Gralla, George Magoufis, and Guillaume Turc

Subjects
medicine.medical_specialty, Outcome Assessment, medicine.medical_treatment, 610 Medicine & health, Fibrinolytic Agents, Modified Rankin Scale, Internal medicine, Outcome Assessment, Health Care, medicine, Humans, Adverse effect, Ischemic Stroke, Randomized Controlled Trials as Topic, business.industry, Endovascular Procedures, Odds ratio, Thrombolysis, Combined Modality Therapy, Confidence interval, 3. Good health, Clinical trial, Health Care, Critical appraisal, Tissue Plasminogen Activator, Meta-analysis, Neurology (clinical), business, 610 Medizin und Gesundheit
Abstract

ObjectiveTo provide a critical appraisal on the evidence from randomized controlled clinical trials (RCTs) on the utility of direct endovascular treatment (dEVT) compared to the combination of endovascular treatment preceded by IV thrombolysis (bridging therapy [BT]) for patients with acute large vessel occlusion (LVO).MethodsEligible RCTs were identified by searching Medline and Scopus. We calculated the corresponding odds ratios (ORs) and 95% confidence intervals (CIs) and pooled estimates using random-effects models. The primary outcome was the probability of modified Rankin scale (mRS) score of 0 to 2 at 3 months.ResultsWe included 3 studies comprising 1,092 patients. No difference between the dEVT and BT groups was detected for the outcomes of mRS score of 0 to 2 (OR 1.08, 95% CI 0.85–1.38; adjusted OR 1.11, 95% CI 0.76–1.63), mRS score of 0 to 1 (OR 1.10, 95% CI 0.84–1.43; adjusted OR 1.16, 95% CI 0.84–1.61), and functional improvement at 3 months (common OR 1.08, 95% CI 0.88–1.34; adjusted common OR 1.09, 95% CI 0.86–1.37). Patients receiving dEVT had significantly lower likelihood of successful recanalization before the endovascular procedure compared to those receiving BT (OR 0.37, 95% CI 0.18–0.77). Patients receiving dEVT had lower intracranial bleeding rates compared to those receiving BT (OR 0.67, 95% CI 0.49–0.92) but without a significant difference in the probability of symptomatic intracranial hemorrhage. No differences in all-cause mortality, serious adverse events, or procedural complications between the 2 groups were uncovered.ConclusionsWe detected no differences in functional outcomes of IV thrombolysis–eligible patients with an acute LVO receiving dEVT compared to BT. Because uncertainty for most endpoints remains large and the available data are not able to exclude the possibility of overall benefit or harm, further RCTs are needed.

Published
2021
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29. SARS-CoV-2 and Stroke Characteristics: A Report From the Multinational COVID-19 Stroke Study Group

Author

Saeideh Aghayari Sheikh Neshin, Guillaume Turc, Georgios Tsivgoulis, Fahimeh Vahabizad, Stefania Mondello, Oluwaseyi Olulana, Thomas Yasuda, Gelareh Banihashemi, Ali Reza Noorian, Mojdeh Ghabaee, Hany Mohamed Aref, Aristeidis H. Katsanos, Sahar Hojjat-Anasri Komachali, Alaleh Vaghefi Far, Saeed Ansari, Francisco Purroy, Leo H. Bonati, Sakineh Ranji-Burachaloo, Juan F. Arenillas, Afshin Borhani-Haghighi, Peyman Nowrouzi-Sohrabi, Ilaria Gandoglia, Zabihollah Babaeepour, Mohammad Hossein Harirchian, Alia Saberi, Vivek Sharma, Fabricio Buchadid Cardoso, Jusun Moon, Nitin Goyal, Arash Kia, Ronen R. Leker, Mercedeh Sepehrnia, João Sargento-Freitas, Apoorva Dev, Asadollah Mir Ghasemi, Mirna Sabra, Mohammad Ghorbani, Aicha Lyoubi, Bruce C.V. Campbell, Saeideh Salehizadeh, Christos Krogias, Shailesh Male, Mehrdad Roozbeh, Elahe Mohammadi-Vosough, Durgesh Chaudhary, Soheil Naderi, Nasrin Rahimian, Konark Malhotra, Mehmet Hanci, Mehdi Farhoudi, Arefeh Babazadeh, Ali Amini Harandi, Ghasem Farahmand, Massimo Del Sette, Martin Punter, Miljenko Crnjakovic, Faezeh Khodadadi, Gian Marco De Marchis, Ashkan Mowla, Nuno Reis Carreira, Fariborz Khorvash, Annemarei Ranta, Zeinab Mohseni Afshar, Orkhan Alizada, Shima Shahjouei, Ana Paula Aires, Diana Aguiar de Sousa, Christoph J. Griessenauer, Ava Hamidi, Seyed Amir Ebrahimzadeh, Farhad Assarzadegan, Jong Ho Park, Hamidreza Mirkarimi, Mostafa Almasi-Dooghaee, Achille Cernigliaro, Jeffrey C Mai, Lawrence Nolan, Mahmoud Reza Azarpazhooh, Leila Poorsaadat, Yasaman Ahmadzadeh, João Pedro Marto, Humain Baharvahdat, Kristi Tempro, Seyed Aidin Sajedi, Teresa Mesquita, Bruno Gonçalves, Venkatesh Avula, Manuel Requena, Jason J. Chang, Mika Niemelä, Zeynab Sadat Hasheminejad, Branko Malojčić, Elsa Azevedo, Abhi Pandhi, Debdipto Misra, Ramin Zand, Vida Abedi, Marta Rubiera, Thorsten Steiner, Alireza Vafaei Sadr, Sepideh Paybast, Rohan Arora, Behnam Rezai Jahromi, Firas Kobeissy, Jiang Li, Daniel Bock, Behnam Sabayan, Eric Koza, Joan Montaner, Lev Lotman, Mercedes de Lera Alfonso, Carlo W. Cereda, Mahtab Ramezani, Matthew S. Tenser, Duchange, Nathalie, Geisinger Health System [Danville, PA, USA], National and Kapodistrian University of Athens (NKUA), Attikon University Hospital, Tehran University of Medical Sciences (TUMS), Geisinger Commonwealth School of Medicine [Scranton, PA, USA], University of Southern California (USC), Université de Genève = University of Geneva (UNIGE), Icahn School of Medicine at Mount Sinai [New York] (MSSM), University of Messina, Regional Health Authority of Sicily [Palermo], University of Otago [Dunedin, Nouvelle-Zélande], PES University [Bangalore], Lebanese University [Beirut] (LU), Shahid Beheshti University of Medical Sciences [Tehran] (SBUMS), Hôpital Delafontaine, Centre Hospitalier de Saint-Denis [Ile-de-France], University of Melbourne, Universidad de Valladolid [Valladolid] (UVa), Klinikum Frankfurt Höchst, University Hospital Virgen Macarena [Sevilla], Poursina Hospital, Universidade de Lisboa = University of Lisbon (ULISBOA), Centro Hospitalar Universitário de São João [Porto], Universidade do Porto = University of Porto, Cerrahpasa Faculty of Medicine, Istanbul University, University of Tennessee [Chattanooga] (UTC), Valiasr Hospital [Borujen], University Hospital Basel [Basel], Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, MedStar Washington Hospital Center, Clinical Hospital Dubrava [Zagreb, Croatia] (CHD), University of Basel (Unibas), Galliera Hospital [Genova, Italy], Yasrebi Hospital [Kashan, Iran] (YH), Tabriz University of Medical Sciences [Tabriz, Iran] (TUOMS), Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), McMaster University [Hamilton, Ontario], Ruhr University Bochum (RUB), Hadassah Hebrew University Medical Center [Jerusalem], Albany Medical College, Georgetown University Medical Center, Vidant Medical Center [Greenville, NC, USA] (VMC), Allegheny Health Network [Pittsburgh, PA, USA] (AHN), University Hospital Centre Zagreb, Partenaires INRAE, University of Zagreb, Hospital De Egas Moniz [Lisbon], University of Ottawa [Ottawa], Ain Shams University (ASU), Kermanshah University of Medical Sciences, Asan Medical Center [Seoul], University of Ulsan, Helsingin yliopisto = Helsingfors universitet = University of Helsinki, Helsinki University Hospital, Hanyang University College of Medicine, Universitat de Lleida, Vall d'Hebron University Hospital [Barcelona], Universitat Autònoma de Barcelona (UAB), Golestan University of Medical Sciences, Universidade de Coimbra [Coimbra], National University Health System [Singapore] (NUHS), Heidelberg University Hospital [Heidelberg], Hospital for Special Surgery, Iran University of Medical Sciences, Shahid Beheshti University, Babol University of Medical Sciences, Mashhad University of Medical Sciences, Centro Médico de Campinas [São Paulo], Gheshm Hospital, Gilan University of Medical Sciences [Lahijan], Isfahan University of Medical Sciences [Iran] (MUI), University of Florida [Gainesville] (UF), Modarres Hospital [Kashmar], Southern California Permanente Medical Group, Shiraz University of Medical Sciences [Iran] (SUMS), Qazvin University of Medical Sciences, Arak University of Medical Sciences, Harvard Medical School [Boston] (HMS), Salahadin Ayubi Hospital [Baneh], University of Western Ontario (UWO), Long Island Jewish Forest Hills [New York], Biocomplexity Institute of Virginia Tech [Blacksburg], Virginia Tech [Blacksburg], Department of Neurosciences, HUS Neurocenter, Neurokirurgian yksikkö, Clinicum, University of Geneva [Switzerland], Universidade de Lisboa (ULISBOA), Universidade do Porto, Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Hospital De Egas Moniz [Lisbon, Portugal] (Centro Hospitalar Lisboa Ocidental), and University of Helsinki

Subjects
Male, Cerebrovascular disorders, MESH: Geography, Epidemiology, International Cooperation, SUBTYPES, 0302 clinical medicine, [SDV.MHEP.MI]Life Sciences [q-bio]/Human health and pathology/Infectious diseases, Prospective Studies, Young adult, Cerebral Venous Thrombosis, MESH: Treatment Outcome, Subtypes, neuroimaging, MESH: Middle Aged, MESH: Risk, Geography, STATEMENT, cerebrovascular disorders, intracranial hemorrhages, stroke, venous thrombosis, virus diseases, Countries, 3. Good health, MESH: Young Adult, Cardiology and Cardiovascular Medicine, MESH: Intracranial Hemorrhages, COUNTRIES, medicine.medical_specialty, Registry, MESH: Health Expenditures, 03 medical and health sciences, 1ST-EVER ISCHEMIC-STROKE, [SDV.MHEP.CSC]Life Sciences [q-bio]/Human health and pathology/Cardiology and cardiovascular system, Humans, Aged, Ischemic Stroke, Advanced and Specialized Nursing, MESH: Humans, 3112 Neurosciences, MESH: Adult, medicine.disease, MESH: International Cooperation, nervous system, RISK-FACTORS, Observational study, Neurology (clinical), Statement, Health Expenditures, Young-Adults, MESH: Female, 030217 neurology & neurosurgery, viruses, 030204 cardiovascular system & hematology, Sinus Thrombosis, Intracranial, Venous thrombosis, YOUNG-ADULTS, Risk-Factors, EPIDEMIOLOGY, MESH: COVID-19, Prospective cohort study, Stroke, MESH: Aged, musculoskeletal, neural, and ocular physiology, CEREBRAL VENOUS THROMBOSIS, Middle Aged, [SDV.MHEP.CSC] Life Sciences [q-bio]/Human health and pathology/Cardiology and cardiovascular system, Treatment Outcome, MESH: Sinus Thrombosis, Intracranial, [SDV.MHEP.MI] Life Sciences [q-bio]/Human health and pathology/Infectious diseases, Female, medicine.symptom, Interstroke, MESH: Ischemic Stroke, Adult, Risk, Subarachnoid hemorrhage, Coronavirus disease 2019 (COVID-19), Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Neuroimaging, macromolecular substances, Asymptomatic, Young Adult, INTERSTROKE, Aneurysm, Internal medicine, medicine, cardiovascular diseases, business.industry, COVID-19, Artery occlusions, MESH: Male, MESH: Prospective Studies, Intracranial hemorrhages, REGISTRY, MESH: Venous Thrombosis, 1st-Ever Ischemic-Stroke, business
Abstract

Background and Purpose: Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale. Methods: We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes. Results: Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were P =0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P Conclusions: We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.

Published
2021
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30. Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone

Author

Aïcha Lyoubi, Charles Arteaga, Caroline Arquizan, Philippe Niclot, Aude Triquenot, Charlotte Rosso, Laurent Suissa, Laurie Fraticelli, Frédéric Klapczynski, Marion Boulanger, Christine Pires, Patrik Michel, Didier Leys, Philippe Smadja, Mathilde Delpech, Stéphane Vannier, Yves Berthezène, Sébastien Richard, Sébastien Gazzola, Serge Timsit, Valérie Wolff, Jérémie Papassin, Laurent Spelle, Christian Denier, Yannick Béjot, Jean-Louis Mas, Anne-Evelyne Vallet, Catherine Oppenheim, Séverine Debiais, Serge Bracard, Olivier Detante, Andreea Aignatoaie, Frédéric Philippeau, François Lun, Denis Sablot, Emmanuel Touzé, Valer Grigoras, Sébastien Marcel, Hervé Brunel, Laura Mechtouff, Hubert Desal, Mirjam Rachel Heldner, Bertrand Lapergue, Vincent Costalat, Serkan Cakmak, Duc-Long Duong, Isabelle Serre, François Mounier-Vehier, Audrey Courselle-Arnoux, Sébastien Soize, Ludovic Lucas, Pierre Agius, Sonia Alamowitch, Isabelle Girard Buttaz, Michel Piotin, Pierre Garnier, Gauthier Duloquin, Davide Strambo, Nicolas Bricout, Omar Bennani, Emmanuel Carrera, Marion Yger, Hilde Hénon, Jean-Philippe Cottier, Nicolae Crainic, Michael Obadia, Cécile Preterre, Guillaume Turc, Steven Hajdu, Pierre Seners, Mathieu Zuber, Jean-Claude Baron, C. Lamy, Wagih Ben Hassen, Claire Perrin, Claire Boutet, Matthieu Krug, Clement Tracol, Amélie Tuffal, Norbert Nighoghossian, Arnaud Malbranque, Jan Gralla, Yves Samson, Benoit Guillon, Alexandre Obadia, Nadia Laksiri, Ruben Tamazyan, Mylène Masson, Frédéric Clarençon, Canan Ozsancak, Fernando Pico, Gioia Mione, Simon Jung, Mohamed Chbicheb, Igor Sibon, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Hôpital Foch [Suresnes], Hôpital Gui de Chauliac, Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Bern University Hospital [Berne] (Inselspital), Troubles cognitifs dégénératifs et vasculaires - U 1171 (TCDV), Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille)-Institut National de la Santé et de la Recherche Médicale (INSERM), Centre Hospitalier Universitaire Vaudois [Lausanne] (CHUV), Hôpital Bretonneau, Centre Hospitalier Régional Universitaire de Tours (CHRU Tours), Centre Hospitalier Saint Jean de Perpignan, Centre hospitalier [Valenciennes, Nord], Centre hospitalier Saint-Joseph [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Centre hospitalier universitaire de Nantes (CHU Nantes), Centre hospitalier de Saint-Nazaire, Hôpital de la Timone [CHU - APHM] (TIMONE), Hospices Civils de Lyon (HCL), Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand (CHU Dijon), Centre Hospitalier de Versailles André Mignot (CHV), Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), Centre Hospitalier de Lens, Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Institut du Cerveau et de la Moëlle Epinière = Brain and Spine Institute (ICM), Institut National de la Santé et de la Recherche Médicale (INSERM)-CHU Pitié-Salpêtrière [AP-HP], Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Centre National de la Recherche Scientifique (CNRS), CHU Bordeaux [Bordeaux], CHU Grenoble, Université Joseph Fourier - Grenoble 1 (UJF)-CHU Grenoble, Centre Hospitalier Métropole Savoie [Chambéry], Centre Hospitalier Régional d'Orléans (CHRO), CHU Rouen, Normandie Université (NU), Hôpitaux Universitaires de Genève (HUG), Centre Hospitalier René Dubos [Pontoise], Fondation Ophtalmologique Adolphe de Rothschild [Paris], Hôpital Delafontaine, Centre Hospitalier de Saint-Denis [Ile-de-France], Centre Hospitalier Universitaire de Saint-Etienne (CHU de Saint-Etienne), Centre Hospitalier Régional Universitaire de Brest (CHRU Brest), CHU Strasbourg, Centre Hospitalier Universitaire [Rennes], Centre Hospitalier Fleyriat [Bourg en Bresse], CHU Amiens-Picardie, Centre Hospitalier Universitaire de Reims (CHU Reims), MINOR-STROKE Collaborators : Sonia Alamowitch, Charles Arteaga, Omar Bennani, Yves Berthezene, Marion Boulanger, Claire Boutet, Serge Bracard, Nicolas Bricout, Hervé Brunel, Serkan Cakmak, Mohamed Chbicheb, Frédéric Clarençon, Vincent Costalat, Audrey Courselle-Arnoux, Séverine Debiais, Mathilde Delpech, Christian Denier, Hubert Desal, Olivier Detante, Gauthier Duloquin, Laurie Fraticelli, Sébastien Gazzola, Jan Gralla, Valer Grigoras, Benoit Guillon, Matthieu Krug, Steven Hajdu, Simon Jung, Frédéric Klapczynski, Didier Leys, François Lun, Arnaud Malbranque, Sébastien Marcel, Patrik Michel, Jean-Louis Mas, Mylène Masson, Norbert Nighoghossian, Michael Obadia, Catherine Oppenheim, Canan Ozsancak, Fernando Pico, Michel Piotin, Christine Pires, Sébastien Richard, Yves Samson, Isabelle Serre, Igor Sibon, Philippe Smadja, Laurent Spelle, Laurent Suissa, Serge Timsit, Emmanuel Touzé, Amélie Tuffal, Anne-Evelyne Vallet, Marion Yger, Stéphane Vannier, Mathieu Zuber., Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Hôpital Gui de Chauliac [CHU Montpellier], Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Institut du Cerveau = Paris Brain Institute (ICM), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-CHU Pitié-Salpêtrière [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Sorbonne Université (SU)-Sorbonne Université (SU)-Centre National de la Recherche Scientifique (CNRS), Centre Hospitalier Universitaire de Saint-Etienne [CHU Saint-Etienne] (CHU ST-E), Laboratoire de Neurosciences Fonctionnelles et Pathologies - UR UPJV 4559 (LNFP), Université de Picardie Jules Verne (UPJV), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)-Sorbonne Université (SU)-Centre National de la Recherche Scientifique (CNRS), and Martinez Rico, Clara

Subjects
medicine.medical_specialty, medicine.medical_treatment, Population, 03 medical and health sciences, 0302 clinical medicine, Interquartile range, Internal medicine, medicine.artery, Occlusion, medicine, 030212 general & internal medicine, 10. No inequality, education, 610 Medicine & health, Stroke, Original Investigation, education.field_of_study, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, business.industry, [SCCO.NEUR]Cognitive science/Neuroscience, [SCCO.NEUR] Cognitive science/Neuroscience, Retrospective cohort study, Thrombolysis, medicine.disease, ddc:616.8, Cohort, Cardiology, Neurology (clinical), Internal carotid artery, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Importance The best reperfusion strategy in patients with acute minor stroke and large vessel occlusion (LVO) is unknown. Accurately predicting early neurological deterioration of presumed ischemic origin (ENDi) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy. Objective To develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke and LVO. Design, Setting, and Participants This multicentric retrospective cohort included 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score of 5 or less) and LVO (basilar artery, internal carotid artery, first [M1] or second [M2] segment of middle cerebral artery) intended for IVT alone in 45 French stroke centers, ie, including those who eventually received rescue thrombectomy because of ENDi. For external validation, another cohort of 347 patients with similar inclusion criteria was collected from 9 additional centers. Data were collected from January 2018 to September 2019. Main Outcomes and Measures ENDi, defined as 4 or more points' deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause. Results Of the 729 patients in the derivation cohort, 335 (46.0%) were male, and the mean (SD) age was 70 (15) years; of the 347 patients in the validation cohort, 190 (54.8%) were male, and the mean (SD) age was 69 (15) years. In the derivation cohort, the median (interquartile range) NIHSS score was 3 (1-4), and the occlusion site was the internal carotid artery in 97 patients (13.3%), M1 in 207 (28.4%), M2 in 395 (54.2%), and basilar artery in 30 (4.1%). ENDi occurred in 88 patients (12.1%; 95% CI, 9.7-14.4) and was strongly associated with poorer 3-month outcomes, even in patients who underwent rescue thrombectomy. In multivariable analysis, a more proximal occlusion site and a longer thrombus were independently associated with ENDi. A 4-point score derived from these variables-1 point for thrombus length and 3 points for occlusion site-showed good discriminative power for ENDi (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (ENDi rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, ENDi probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively. Conclusions and Relevance The substantial ENDi rates observed in these cohorts highlights the current debate regarding whether to directly transfer patients with IVT-treated minor stroke and LVO for additional thrombectomy. Based on the strong associations observed, an easily applicable score for ENDi risk prediction that may assist decision-making was derived and externally validated.

Published
2021
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31. Distinct serum anti-Aβ antibody patterns in hemorrhagic and inflammatory cerebral amyloid angiopathy manifestations

Author

Corina Cret, Zina Barrou, Pierre Aucouturier, Xavier Ayrignac, Anne Wacongne, Dimitri Renard, Thibault Allou, Sonia Alamowitch, Thomas Chaigneau, Guillaume Turc, Johanna Felix, Marie Sarazin, Jean Capron, Thomas de Broucker, Charlotte Cordonnier, Florian Kruse, Yannick Chantran, Guillaume Dorothée, Diana Doukhi, Mélanie Féroul, and Roxane Peres

Subjects
biology, business.industry, nutritional and metabolic diseases, Context (language use), Inflammation, medicine.disease, Serology, Antibody Isotype, mental disorders, Monoclonal, Immunology, biology.protein, medicine, Avidity, cardiovascular diseases, Cerebral amyloid angiopathy, Antibody, medicine.symptom, business
Abstract

ObjectiveTo study blood anti-Aβ antibodies in the context of spontaneous inflammatory or hemorrhagic CAA manifestations, which are similar to complications occurring after monoclonal anti-Aβ antibody immunotherapies.MethodsIn this case-control study, serum anti-Aβ antibody isotype, concentration, avidity, and reactivity toward soluble or fibrillary Aβ1-40 and Aβ1-42 isoforms were assessed using an ELISA-based multiplex analysis. Anti-Aβ serologic patterns were defined in CAA and CAA subgroups using multivariable logistic regression analyses.ResultsFourty-one healthy aged controls and 64 CAA patients were recruited: 46 with hemorrhagic features (CAA-he) and 18 with CAA-related inflammation (CAA-ri). As compared to controls, the most striking features of CAA-related serological profiles were the following: i) both CAA-he and CAA-ri patients displayed lower binding diversity of anti-soluble Aβ1-40 IgM; ii) CAA-he patients displayed higher anti-soluble Aβ1-40 / fibrillary Aβ1-42 IgG4 concentrations ratio and higher anti-soluble Aβ1-42 IgG4 and IgA avidity; iii) CAA-ri patients displayed higher binding diversity of anti-soluble Aβ1-40 IgG3 and higher anti-fibrillary/soluble Aβ1-42 IgG4 dilution curve steepness ratio.ConclusionThis proof-of-concept study revealed anti-Aβ antibody variations in CAA patients, some of which were associated to CAA clinical phenotypes, unveiling pathophysiological insights regarding CAA-hemorrhagic and inflammatory related events.

Published
2020
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32. Tissue no-reflow despite full recanalization following thrombectomy for anterior circulation stroke with proximal occlusion: A clinical study

Author

Sylvain Charron, Adrien Ter Schiphorst, Wagih Ben Hassen, Corentin Provost, Pierre Seners, Guillaume Turc, Jean-Claude Baron, Joseph Benzakoun, Catherine Oppenheim, Olivier Naggara, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Département de neurologie [Montpellier], Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Gui de Chauliac [Montpellier]-Université de Montpellier (UM), Service de neuroradiologie [Paris], Hôpital Sainte-Anne, Département de Neurologie [Hôpital Sainte-Anne - APHP] (Paris CB2 2QQ), Centre Hospitalier Sainte Anne [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), and Martinez Rico, Clara

Subjects
medicine.medical_specialty, medicine.medical_treatment, cerebral blood flow, Infarction, Key-words: perfusion, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, large vessel occlusion, medicine, cardiovascular diseases, Stroke, Proximal occlusion, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, cerebral infarction diaschisis, Cerebral infarction, business.industry, Thrombolysis, medicine.disease, cerebral infarction, arterial spin labeling, Perfusion, Neurology, Cerebral blood flow, Cohort, Cardiology, Neurology (clinical), arterial spin labelling, Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

International audience; Despite early thrombectomy, a sizeable fraction of acute stroke patients with large vessel occlusion have poor outcome. The no-reflow phenomenon, i.e. impaired microvascular reperfusion despite complete recanalization, may contribute to such "futile recanalizations". Although well reported in animal models, no-reflow is still poorly characterized in man. From a large prospective thrombectomy database, we included all patients with intracranial proximal occlusion, complete recanalization (modified thrombolysis in cerebral infarction score 2c-3), and availability of both baseline and 24 h follow-up MRI including arterial spin labeling perfusion mapping. No-reflow was operationally defined as i) hypoperfusion ≥40% relative to contralateral homologous region, assessed with both visual (two independent investigators) and automatic image analysis, and ii) infarction on follow-up MRI. Thirty-three patients were eligible (median age: 70 years, NIHSS: 18, and stroke onset-to-recanalization delay: 208 min). The operational criteria were met in one patient only, consistently with the visual and automatic analyses. This patient recanalized 160 min after stroke onset and had excellent functional outcome. In our cohort of patients with complete and stable recanalization following thrombectomy for intracranial proximal occlusion, severe ipsilateral hypoperfusion on follow-up imaging associated with newly developed infarction was a rare occurrence. Thus, no-reflow may be infrequent in human stroke and may not substantially contribute to futile recanalizations.

Published
2020
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33. Predictors of Unexplained Early Neurological Deterioration After Endovascular Treatment for Acute Ischemic Stroke

Author

Jean-Baptiste Girot, Sébastien Richard, Florent Gariel, Igor Sibon, Julien Labreuche, Maéva Kyheng, Benjamin Gory, Cyril Dargazanli, Benjamin Maier, Arturo Consoli, Benjamin Daumas-Duport, Bertrand Lapergue, Romain Bourcier, Michel Piotin, Raphael Blanc, Hocine Redjem, Simon Escalard, Jean-Philippe Desilles, Gabriele Ciccio, Stanislas Smajda, Mikael Mazighi, Mikael Obadia, Candice Sabben, Roxanne Peres, Ovide Corabianu, Thomas de Broucker, Didier Smadja, Sonia Alamowitch, Olivier Ille, Eric Manchon, Pierre-Yves Garcia, Guillaume Taylor, Malek Ben Maacha, Adrien Wang, Serge Evrard, Maya Tchikviladze, Nadia Ajili, David Weisenburger, Lucas Gorza, Géraldine Buard, Oguzhan Coskun, Federico Di Maria, Georges Rodesh, Sergio Zimatore, Morgan Leguen, Julie Gratieux, Fernando Pico, Haja Rakotoharinandrasana, Philippe Tassan, Roxanna Poll, Sylvie Marinier, Norbert Nighoghossian, Roberto Riva, Omer Eker, Francis Turjman, Laurent Derex, Tae-Hee Cho, Laura Mechtouff, Anne Claire Lukaszewicz, Frédéric Philippeau, Serkan Cakmak, Karine Blanc-Lasserre, Anne-Evelyne Vallet, Gaultier Marnat, Xavier Barreau, Jérôme Berge, Louis Veunac, Patrice Menegon, Ludovic Lucas, Stéphane Olindo, Pauline Renou, Sharmila Sagnier, Mathilde Poli, Sabrina Debruxelles, Thomas Tourdias et Jean-Sebastien Liegey, Lili Detraz, Pierre-Louis Alexandre, Monica Roy, Cédric Lenoble, Vincent L’allinec, Hubert Desal, Benoît Guillon, Solène de Gaalon, Cécile Preterre, Serge Bracard, René Anxionnat, Marc Braun, Anne-Laure Derelle, Romain Tonnelet, Liang Liao, François Zhu, Emmanuelle Schmitt, Sophie Planel, Lisa Humbertjean, Gioia Mione, Jean-Christophe Lacour, Mathieu Bonnerot, Nolwenn Riou-Comte, Francisco Macian-Montoro, Suzanna Saleme, Charbel Mounayer, Aymeric Rouchaud, Vincent Costalat, Caroline Arquizan, Grégory Gascou, Pierre-Henri Lefèvre, Imad Derraz, Carlos Riquelme, Nicolas Gaillard, Isabelle Mourand, Lucas Corti, Eugene Francois, Stéphane Vannier, Jean-Christophe Ferre, Helene Raoult, Thomas Ronziere, Maria Lassale, Christophe Paya, Jean-Yves Gauvrit, Clément Tracol, Sophie Langnier-Lemercier, Yves Samson, Charlotte Rosso, Anne Leger, Sandrine Deltour, Frederic Clarencon, Eimad Shotar, Laurent Spelle, Christian Denier, Olivier Chassin, Vanessa Chalumeau, Jildaz Caroff, Laura Venditti, Guillaume Turc, Glivier Naggara, Gregoire Boulouis, Waghih Ben Hassen, Pierre Seners, Alain Viguier, Christophe Cognard, Anne Christine Januel, Jean-Marc Olivot, Nicolas Raposo, Fabrice Bonneville, Emmanuel Touze, Charlotte Barbier, Romain Schneckenburger, Marion Boulanger, Julien Cogez, Sophie Guettier, Département de Neuro-Radiologie [Angers] (DNR - Angers), Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM)-PRES Université Nantes Angers Le Mans (UNAM), Département de Neuroradiologie [St Herblain], Hôpital Guillaume-et-René-Laennec [Saint-Herblain], Défaillance Cardiovasculaire Aiguë et Chronique (DCAC), Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Centre d'investigation clinique plurithématique Pierre Drouin [Nancy] (CIC-P), Centre d'investigation clinique [Nancy] (CIC), Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL)-Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Département de Neuro-Radiologie [Bordeaux] (DNR - Bordeaux), CHU Bordeaux [Bordeaux], Service de neurologie [Bordeaux], CHU Bordeaux [Bordeaux]-Groupe hospitalier Pellegrin, Evaluation des technologies de santé et des pratiques médicales - ULR 2694 (METRICS), Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Département de Neuroradiologie[Montpellier], Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Gui de Chauliac [CHU Montpellier], Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Université de Montpellier (UM), Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Hôpital Foch [Suresnes], Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Université de Montpellier (UM), Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Gui de Chauliac [Montpellier]-Université de Montpellier (UM), and Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU)

Subjects
Male, medicine.medical_specialty, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, 030204 cardiovascular system & hematology, Brain Ischemia, Brain ischemia, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Risk Factors, Internal medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Medicine, Humans, In patient, Prospective Studies, Registries, Endovascular treatment, Stroke, Acute ischemic stroke, Aged, Thrombectomy, Advanced and Specialized Nursing, Aged, 80 and over, business.industry, Endovascular Procedures, Middle Aged, medicine.disease, Combined Modality Therapy, 3. Good health, Blood pressure, Treatment Outcome, Ischemic stroke, Cardiology, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Background and Purpose: Although the efficacy of endovascular treatment (EVT) in patients with anterior circulation ischemic stroke (AIS) is well documented, early neurological deterioration after EVT remains a serious issue associated with poor outcome. Besides obvious causes, such as lack of reperfusion, procedural complications, or parenchymal hemorrhage, early neurological deterioration may remain unexplained (UnEND). Our aim was to investigate predictors of UnEND after EVT in patients with AIS. Methods: Patients who underwent EVT for AIS, with an initial National Institutes of Health Stroke Scale score >5, Alberta Stroke Program Early CT Score ≥6, and included in a multicenter prospective observational registry were analyzed. Predictors of UnEND, defined as ≥4-point increase in the National Institutes of Health Stroke Scale score between baseline and day 1 after EVT, were determined via center-adjusted analyses. Results: Among the 1925 included in the analysis, 128 UnEND (6.6%) were recorded. In multivariate analysis, predictors of UnEND were diabetes mellitus (odds ratio [OR], 2.17 [95% CI, 1.32–3.56]), prestroke modified Rankin Scale score ≥2 (OR, 2.22 [95% CI, 1.09–4.55]), general anesthesia (OR, 2.55 [95% CI, 1.51–4.30]), admission systolic blood pressure (OR, 1.10 [95% CI, 1.01–1.20]), age (OR, 1.38 [95% CI, 1.14–1.67]), number of passes (OR, 1.16 [95% CI, 1.04–1.28]), direct admission or not to a comprehensive stroke center (OR, 0.49 [95% CI, 0.30–0.81]), and initial National Institutes of Health Stroke Scale score (OR, 0.65 [95% CI, 0.52–0.81]). Conclusions: Severely impaired AIS patients with nonmodifiable factors are more likely to develop UnEND. Some modifiable predictors of UnEND such as the number of EVT passes could be the object of improvement in AIS management.

Published
2020
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34. Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke

Author

Arvind Chandratheva, George Ntaios, Per Meden, Michael V. Mazya, Tiago Moreira, Gheorghe Andrei Dan, Fabio Bandini, Eleni Korompoki, María Alonso de Leciñana, Guillaume Turc, Antonio Gil-Núñez, Jukka Putaala, Marjaana Tiainen, Paulo F. Castañeda-Méndez, Fernando Ostos, Stavropoula Tjoumakaris, Jaume Roquer, Robert Simister, Bernd Lamprecht, Alicia DeFelipe, Milan R. Vosko, Carlo W. Cereda, Andrés García-Pastor, Helle K. Iversen, Cristina Tiu, Luis Enrique Soto-Ramírez, Fernando Díaz-Otero, Alejandra González-Duarte, Martin W. Dünser, Louisa M. Christensen, Jaime Masjuan, Laura A Benjamin, Richard J. Perry, Ángel Basilio Corredor Quintero, David J. Werring, Roxana Vezeteu, Espen Saxhaug Kristoffersen, Ángela Rodríguez-López, Patricia Calleja, Errikos Maslias, Hanne Christensen, Antonio Arauz, Guillermo González-Ortega, Daniel Strbian, Elisa Cuadrado-Godia, Eduardo Soriano-Navarro, Wencheng Li, Patrik Michel, Blanca Fuentes, Julia Ferrari, Jing Xiong, Rahma Beyrouti, Exuperio Díez-Tejedor, Gregory Y.H. Lip, Helmut J. F. Salzer, Daniela Bay-Sansores, Lejla Hajdarevic, Yutao Guo, Vanessa Cano-Nigenda, Sebastián García-Madrona, Valerie Domigo, Ana Rodríguez Campello, Pascal Jabbour, Georgios Georgiopoulos, Bruno Gonçalves, Davide Strambo, Ahmad Sweid, Karl Matz, University of Thessaly [Larissa], Université de Lausanne (UNIL), King‘s College London, Chinese PLA General Hospital, Huazhong University of Science & Technology, Instituto de Investigación Hospital Universitario 12 de Octubre, Doce de Octubre University Hospital, La Paz University Hospital, IdiPAZ Health Research Institute, Ramon & Cajal University Hospital, IRYCIS Health Research Institute, GHU Paris Psychiatrie et Neurosciences, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Paulo Niemeyer State Brain Institute, Colentina University Hospital, University of Medicine and Pharmacy 'Carol Davila' Bucharest (UMPCD), Bispebjerg Hospital, University of Copenhagen = Københavns Universitet (KU), Hospital General Universitario 'Gregorio Marañón' [Madrid], UCL Institute of Neurology, Queen Square, London, Thomas Jefferson University Hospitals, IMIM-Hospital del Mar, Generalitat de Catalunya, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra [Barcelona] (UPF), Karolinska Institutet [Stockholm], San Paolo Hospital [Savona], Donau-Universität Krems, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán - National Institute of Medical Science and Nutrition Salvador Zubiran [Mexico], University Emergency Hospital [Bucharest], Kepler University Hospital, Johannes Kepler Universität Linz (JKU), Stroke Center EOC, Neurocenter of Southern Switzerland, Hospital Departamental Universitario del Quindío San Juan de DiosArmenia, National and Kapodistrian University of Athens (NKUA), Fundación Clínica Médica Sur [Mexico City], Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez [Mexico], Akershus University Hospital [Lørenskog], University of Oslo (UiO), Helsinki University Hospital, University of Liverpool, Liverpool Heart & Chest Hospital, Aalborg University [Denmark] (AAU), Université de Lausanne = University of Lausanne (UNIL), Huazhong University of Science and Technology [Wuhan] (HUST), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), University of Copenhagen = Københavns Universitet (UCPH), and Martinez Rico, Clara

Subjects
Male, Coronavirus Infections/complications, coronavirus, 030204 cardiovascular system & hematology, Brain Ischemia, Cohort Studies, Disability Evaluation, Brain Ischemia/complications, 0302 clinical medicine, Interquartile range, Medicine, Registries, 10. No inequality, Stroke, Aged, 80 and over, education.field_of_study, [SDV.MHEP] Life Sciences [q-bio]/Human health and pathology, survivors, Middle Aged, 3. Good health, Treatment Outcome, Cohort, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Female, Coronavirus Infections, Cardiology and Cardiovascular Medicine, Cohort study, medicine.medical_specialty, Pneumonia, Viral, Population, Time-to-Treatment, 03 medical and health sciences, Internal medicine, Humans, Propensity Score, education, Special Report, Pandemics, propensity score, Survival analysis, Aged, Advanced and Specialized Nursing, business.industry, COVID-19, Recovery of Function, Odds ratio, medicine.disease, Survival Analysis, Brain Ischemia/diagnostic imaging, Brain Ischemia/therapy, Coronavirus Infections/diagnostic imaging, Coronavirus Infections/therapy, Pneumonia, Viral/complications, Pneumonia, Viral/diagnostic imaging, Pneumonia, Viral/therapy, Stroke/complications, Stroke/diagnostic imaging, Stroke/therapy, Tomography, X-Ray Computed, prognosis, Propensity score matching, Neurology (clinical), business, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, 030217 neurology & neurosurgery
Abstract

Supplemental Digital Content is available in the text., Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institute of Health Stroke Scale was 10 (interquartile range [IQR], 4–18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institute of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4–18] versus 6 [IQR, 3–14]), P=0.03; (odds ratio, 1.69 [95% CI, 1.08–2.65] for higher National Institute of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2–6] versus 2 [IQR, 1–4], P

Published
2020
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35. Mechanical Thrombectomy for Acute Ischemic Stroke Amid the COVID-19 Outbreak: Decreased Activity, and Increased Care Delays

Author

Basile Kerleroux, Thibaut Fabacher, Nicolas Bricout, Martin Moïse, Benoit Testud, Sivadji Vingadassalom, Héloïse Ifergan, Kévin Janot, Arturo Consoli, Wagih Ben Hassen, Eimad Shotar, Julien Ognard, Guillaume Charbonnier, Vincent L’Allinec, Alexis Guédon, Federico Bolognini, Gaultier Marnat, Géraud Forestier, Aymeric Rouchaud, Raoul Pop, Nicolas Raynaud, François Zhu, Jonathan Cortese, Vanessa Chalumeau, Jérome Berge, Simon Escalard, Grégoire Boulouis, Cyril Chivot, Riyad Hanafi, Anne Pasco, Jean-Baptiste Girot, Alessandra Biondi, Fortunato Di Caterino, Panagiotis Primikiris, Giovanni Vitale, Louise Bonnet, Florent Gariel, Xavier Barreau, Sabrina Debruxelles, Ludovic Lucas, Patrice Menegon, Stéphane Olindo, Mathilde Poli, Pauline Renou, Sharmila Sagnier, Igor Sibon, Louis Veunac, Jean-Christophe Gentric, Charlotte Barbier, Marion Boulanger, Julien Cogez, Sophie Guettier, Romain Schneckenburger, Emmanuel Touze, Mariette Delaitre, Pablo Lebendinsky, Mariano Musacchio, Frédéric Ricolfi, Pierre Thouant, François Caparros, Barbara Casolla, Lucie Della Schiava, Nelly Dequatre, Hilde Henon, Marco Pasi, Apolline Kazemi, Fouzi Bala, Laurent Estrade, Charbel Mounayer, Susanna Saleme, Francisco Macian-Montoro, Omer Eker, François Cotton, Karine Blanc-Lasserre, Serkan Cakmak, Tae-Hee Cho, Laurent Derex, Anne-Claire Lukaszewicz, Laura Mechtouff, Norbert Nighoghossian, Frédéric Philippeau, Roberto Riva, Francis Turjman, Anne-Evelyne Vallet, Xavier Carle, Philippe Dory-Lautrec, Anthony Reyre, Jean-François Hak, Hervé Brunel, Amel Benali, François-Louis Collemiche, Cyril Dargazanli, Frederico Cagnazzo, Imad Derraz, Caroline Arquizan, Lucas Corti, Vincent Costalat, Nicolas Gaillard, Grégory Gascou, Pierre-Henri Lefèvre, Isabelle Mourand, Carlos Riquelme, Anne Laure Derelle, Benjamin Gory, Liang Liao, Romain Tonnelet, René Anxionnat, Mathieu Bonnerot, Serge Bracard, Marc Braun, Lisa Humbertjean, Jean-Christophe Lacour, Gioia Mione, Sophie Planel, Sébastien Richard, Nolwenn Riou-Comte, Emmanuelle Schmitt, Romain Bourcier, Lili Detraz, Hubert Desal, Pierre-Louis Alexandre, Benjamin Daumas-Duport, Cédric Lenoble, Monica Roy, Oghuzan Coskun, Frederico Di Maria, Bertrand Lapergue, Georges Rodesch, Adrien Wang, David Weisenburger-Lile, Sergio Zimatore, Nadia Ajili, Géraldine Buard, Serge Evrard, Lucas Gorza, Julie Gratieux, Morgan Leguen, Sylvie Marinier, Fernando Pico, Roxanna Poll, Haja Rakotoharinandrasana, Philippe Tassan, Maya Tchikviladze, François Delvoye, Solène Hebert, Raphaël Blanc, Gabriele Ciccio, Jean-Philippe Desilles, Benjamin Maier, Mikael Mazighi, Michel Piotin, Hocine Redjem, Stanislas Smajda, Malek Ben Maacha, Ovide Corabianu, Thomas De Broucker, Olivier Ille, Eric Manchon, Michael Obadia, Mickael Obadia, Igor Raynouard, Roxanne Peres, Candice Sabben, Didier Smadja, Guillaume Taylor, Laurie-Anne Thion, Augustin Lecler, Laurent Spelle, Christian Denier, Jildaz Caroff, Olivier Chassin, laurent Spelle, Laura Venditti, Armand Aymard, Jean Betty, Vittorio Civelli, Michael Eliezer, Matteo Fantoni, Emmanuel Houdart, Marc-Antoine Labeyrie, Jean-Pierre Saint Maurice, Erwah Kalsoum, Aurelien Pacini, Chawkat Ramadane, Titien Tuilier, Adrien Villain, Frédéric Clarencon, Vincent Degos, Ahmed Elhfnawy, Mahmoud Elhorany, Stéphanie Lenck, Kevin Premat, Nader-Antoine Sourour, Sonia Alamowitch, Flore Baronnet, Sophie Crozier, Sandrine Deltour, Anne Leger, Charlotte Rosso, Nadya Pyatigorskaya, Christine Rodriguez Regent, Denis Trystram, Olivier Naggara, Pierre Seners, Guillaume Turc, Myriam Edjlali, Rémi Agbonon, Mohammed Alotaibi, Antoine Sonchet, Catherine Oppenheim, Jean François Meder, Joseph Benzakoun, Laurence Legrand, Cédric Fauché, Stéphane Velasco, Pierre François Manceau, Sebastien Solène Soize Moulin, François Eugene, Jean-Christophe Ferre, Christophe Paya, Jean-Yves Gauvrit, Sophie Langnier-Lemercier, Maria Lassale, helene Raoult, thomas Ronziere, Clément Tracol, Stéphane Vannier, Julien Burel, Julien Le Moal, Chrysanthi Papagiannaki, Mohamed Aggour, Marina Sachet, Claire Boutet, Remy Beaujeux, Anca Hasiu, Monica Manisor, Dan Mihoc, Stéphane Kremer, Charles Arteaga, Sébastien Gazzola, Jean Darcourt, Christophe Cognard, Fabrice Bonneville, Anne Christine Januel, Jean-Marc Olivot, Nicolas Raposo, Alain Viguier, Richard Bibi, Fakhreddine Boustia, Denis Herbreteau, Igor Maldonado, and Ana-Paula Narata

Subjects
Male, 2019-20 coronavirus outbreak, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Mechanical Thrombolysis, Pneumonia, Viral, 030204 cardiovascular system & hematology, medicine.disease_cause, Brain Ischemia, Time-to-Treatment, 03 medical and health sciences, Betacoronavirus, 0302 clinical medicine, Patient Admission, Pandemic, Medicine, Humans, Prospective Studies, Acute ischemic stroke, Pandemics, Coronavirus, Aged, Advanced and Specialized Nursing, Aged, 80 and over, business.industry, SARS-CoV-2, Outbreak, COVID-19, Middle Aged, 3. Good health, Mechanical thrombectomy, Hospitalization, Stroke, Emergency medicine, Female, Neurology (clinical), France, Cardiology and Cardiovascular Medicine, business, Coronavirus Infections, Delivery of Health Care, 030217 neurology & neurosurgery, Procedures and Techniques Utilization
Abstract

Background and Purpose: The efficiency of prehospital care chain response and the adequacy of hospital resources are challenged amid the coronavirus disease 2019 (COVID-19) outbreak, with suspected consequences for patients with ischemic stroke eligible for mechanical thrombectomy (MT). Methods: We conducted a prospective national-level data collection of patients treated with MT, ranging 45 days across epidemic containment measures instatement, and of patients treated during the same calendar period in 2019. The primary end point was the variation of patients receiving MT during the epidemic period. Secondary end points included care delays between onset, imaging, and groin puncture. To analyze the primary end point, we used a Poisson regression model. We then analyzed the correlation between the number of MTs and the number of COVID-19 cases hospitalizations, using the Pearson correlation coefficient (compared with the null value). Results: A total of 1513 patients were included at 32 centers, in all French administrative regions. There was a 21% significant decrease (0.79; [95%CI, 0.76–0.82]; P P P R 2 −0.51; P =0.04). Patients treated during the COVID outbreak were less likely to receive intravenous thrombolysis and to have unwitnessed strokes (both P Conclusions: Our study showed a significant decrease in patients treated with MTs during the first stages of the COVID epidemic in France and alarming indicators of lengthened care delays. These findings prompt immediate consideration of local and regional stroke networks preparedness in the varying contexts of COVID-19 pandemic evolution.

Published
2020

36. Benefit of first-pass complete reperfusion in thrombectomy is mediated by limited infarct growth

Author

Laurence Legrand, Catherine Oppenheim, Gregoire Boulouis, Olivier Naggara, Joseph Benzakoun, Pierre Seners, Mickael Tordjman, W. Ben Hassen, Nicolas Bricout, Myriam Edjlali, Guillaume Turc, Charlotte Cordonnier, Martin Bretzner, and Hilde Hénon

Subjects
medicine.medical_specialty, Population, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Modified Rankin Scale, Internal medicine, medicine, Humans, 030212 general & internal medicine, Prospective Studies, education, Retrospective Studies, Thrombectomy, First pass, education.field_of_study, medicine.diagnostic_test, business.industry, Cerebral infarction, Confounding, Endovascular Procedures, Magnetic resonance imaging, Odds ratio, medicine.disease, Confidence interval, Stroke, Treatment Outcome, Neurology, Infarction, Reperfusion, Cardiology, Neurology (clinical), business, 030217 neurology & neurosurgery
Abstract

Background and purpose The number of clot retrieval attempts required to achieve complete reperfusion by mechanical thrombectomy impacts functional outcome in acute ischaemic stroke (AIS). Complete reperfusion [expanded Treatment In Cerebral Infarction (eTICI) score = 3] at first pass (FP), is associated with the highest rates of favorable outcome compared to complete reperfusion by multiple passes. The aim of the present study was to investigate the relationship between FP complete reperfusion and infarct growth (IG). Methods Anterior AIS patients with baseline and 24-h diffusion-weighted magnetic resonance imaging were included from two prospective registries. IG was measured by voxel-based segmentation of initial and 24-h diffusion-weighted imaging lesions. IG and favorable 3-month modified Rankin Scale (mRS) score (≤ 2) were compared between patients in whom complete reperfusion (eTICI 3) was achieved with a single pass (FP group) and those for whom multiple passes were required (MP group), after matching for confounding factors. Mediation analysis was performed to examine the association between FP and 3-month mRS score, with IG as mediating variable. Results A total of 200 patients were included, of whom 118 (28.9%) had FP complete reperfusion. In case-control analysis, the FP group had lower IG than the MP group [8.7 (5.4-12.9) ml vs. 15.2 (11-22.6) ml, respectively; P = 0.03). Favorable outcome was higher in the FP population compared to a matched MP population (70.9% vs. 53.2%, respectively; P = 0.04). FP compete reperfusion (eTICI 3) was independently associated with favorable outcome in multivariable regression analysis [odds ratio 1.86, 95% confidence interval (CI) 1.01-4.39; P = 0.04]. The effect of complete reperfusion at FP on functional outcome was explained by limited IG in mediation analysis [indirect effect: -0.32 (95% CI -0.47 to -0.09)]. Conclusion Complete reperfusion at FP is independently associated with significant decrease in IG compared to complete reperfusion by multiple attempts, explaining better functional outcomes.

Published
2020

37. Atrial Septal Aneurysm, Shunt Size, and Recurrent Stroke Risk in Patients With Patent Foramen Ovale

Author

Defense-Pfo Trial Investigators, Jae-Kwan Song, Guillaume Turc, Jong S. Kim, Jean-Louis Mas, Eric Brochet, Jong-Young Lee, Close, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), GHU Paris Psychiatrie et Neurosciences, Sungkyunkwan University [Suwon] (SKKU), Service de cardiologie [CHU Bichat], AP-HP - Hôpital Bichat - Claude Bernard [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Université Paris Diderot, Sorbonne Paris Cité, Laboratoire de Recherche Vasculaire Translationnelle (LVTS (UMR_S_1148 / U1148)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP)-Université Sorbonne Paris Nord, University of Ulsan, CLOSE and DEFENSE-PFO Trial Investigators., Martinez Rico, Clara, Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), and Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Université Sorbonne Paris Nord

Subjects
Adult, Male, medicine.medical_specialty, patent foramen ovale, [SDV]Life Sciences [q-bio], Foramen Ovale, Patent, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Interquartile range, Recurrence, Risk Factors, Internal medicine, Antithrombotic, Medicine, Humans, [SDV.NEU] Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], cardiovascular diseases, 030212 general & internal medicine, Prospective Studies, Heart Aneurysm, Stroke, Atrial Septum, business.industry, Proportional hazards model, Hazard ratio, Middle Aged, medicine.disease, stroke, Confidence interval, [SDV] Life Sciences [q-bio], large shunt, Patent foramen ovale, Cardiology, Female, [SDV.NEU]Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Cardiology and Cardiovascular Medicine, business, Shunt (electrical), Vascular Closure Devices, atrial septal aneurysm
Abstract

International audience; BACKGROUND:In patients with patent foramen ovale (PFO)-associated stroke, the presence of large shunt or atrial septal aneurysm (ASA) has been suggested to convey a high risk of stroke recurrence.OBJECTIVES:The purpose of this study was to assess the respective influence of PFO size and ASA status on stroke recurrence under medical therapy in patients with recent PFO-associated stroke without alternative cause.METHODS:The authors pooled individual patient data from 2 prospective observational studies and the medical arms of 2 randomized trials, in which shunt size and ASA status was assessed by independent reading of echocardiographic images. Associations between PFO anatomical features and recurrent ischemic stroke were assessed by mixed effects Cox models.RESULTS:Of 898 patients (mean age 45.3 years), 178 (19.8%) had ASA with large PFO, 71 (7.9%) ASA with nonlarge PFO, 397 (44.2%) large PFO without ASA, and 252 (28.1%) nonlarge PFO without ASA. Over a median follow-up of 3.8 years (interquartile range: 2.6 to 5.5 years), 47 (5.2%) patients experienced a recurrent stroke. There was a heterogeneity across studies for the association between PFO size and stroke recurrence (pinteraction = 0.01). In a model accounting for age, hypertension, antithrombotic therapy, and PFO anatomy, ASA was independently associated with recurrent stroke (adjusted hazard ratio: 3.27; 95% confidence interval: 1.82 to 5.86; p < 0.0001), whereas large PFO was not (average adjusted hazard ratio across studies: 1.43; 95% confidence interval: 0.50 to 4.03; p = 0.50).CONCLUSIONS:In patients with PFO-associated stroke, ASA is a more important predictor of recurrent stroke than shunt size. These results can help to better identify those patients with a high risk of stroke recurrence under medical therapy who may derive the most benefit from PFO closure. (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence [CLOSE]; NCT00562289) (Device Closure versus Medical Therapy in Patients with Cryptogenic Stroke and High-Risk Patent Foramen Ovale [DEFENSE-PFO]; NCT01550588).

Published
2020
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38. European Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE)

Author

Mikael Mazighi, Peter D. Schellinger, Joost de Vries, Kyriakos Lobotesis, Pooja Khatri, Philip White, Guillaume Turc, Urs Fischer, Pervinder Bhogal, Jens Fiehler, and Danilo Toni

Subjects
medicine.medical_specialty, business.industry, Neurological therapy, Other Research Radboud Institute for Health Sciences [Radboudumc 0], MEDLINE, Guideline, Guidelines, medicine.disease, Mechanical thrombectomy, Ischaemic stroke, medicine, In patient, Neurology (clinical), 610 Medicine & health, Cardiology and Cardiovascular Medicine, Intensive care medicine, business, Stroke, Large vessel occlusion
Abstract

Background Mechanical thrombectomy (MT) has become the cornerstone of acute ischaemic stroke management in patients with large vessel occlusion (LVO). The aim of this guideline document is to assist physicians in their clinical decisions with regard to MT. Methods These Guidelines were developed based on the standard operating procedure of the European Stroke Organisation and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. An interdisciplinary working group identified 15 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. Results We found high quality evidence to recommend MT plus best medical management (BMM, including intravenous thrombolysis whenever indicated) to improve functional outcome in patients with LVO-related acute ischaemic stroke within 6 hours after symptom onset. We found moderate quality of evidence to recommend MT plus BMM in the 6-24h time window in patients meeting the eligibility criteria of published randomized trials. These guidelines further detail aspects of prehospital management, patient selection based on clinical and imaging characteristics, and treatment modalities. Conclusions MT is the standard of care in patients with LVO-related acute stroke. Appropriate patient selection and timely reperfusion are crucial. Further randomized trials are needed to inform clinical decision making with regard to the mothership and drip-and-ship approaches, anesthaesia modalities during MT, and to determine whether MT is beneficial in patients with low stroke severity or large infarct volume.

Published
2019

39. European Stroke Organisation (ESO)- European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke

Author

Jens Fiehler, Pervinder Bhogal, Philip White, Danilo Toni, Urs Fischer, Joost de Vries, Mikael Mazighi, Kyriakos Lobotesis, Guillaume Turc, Peter D. Schellinger, and Pooja Khatri

Subjects
medicine.medical_specialty, Mechanical Thrombolysis, medicine.medical_treatment, Brain Ischemia, 030218 nuclear medicine & medical imaging, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, law, Humans, Medicine, 610 Medicine & health, Intensive care medicine, Stroke, Acute ischemic stroke, Societies, Medical, Modalities, business.industry, Patient Selection, Other Research Radboud Institute for Health Sciences [Radboudumc 0], General Medicine, Thrombolysis, medicine.disease, Europe, Mechanical thrombectomy, standards, stroke, thrombectomy, Systematic review, Practice Guidelines as Topic, Reperfusion, Administration, Intravenous, Surgery, Neurology (clinical), business, 030217 neurology & neurosurgery, Standard operating procedure
Abstract

BackgroundMechanical thrombectomy (MT) has become the cornerstone of acute ischemic stroke management in patients with large vessel occlusion (LVO).ObjectiveTo assist physicians in their clinical decisions with regard toMT.MethodsThese guidelines were developed based on the standard operating procedure of the European Stroke Organisation and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. An interdisciplinary working group identified 15 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach.ResultsWe found high-quality evidence to recommend MT plus best medical management (BMM, including intravenous thrombolysis whenever indicated) to improve functional outcome in patients with LVO-related acute ischemic stroke within 6 hours after symptom onset. We found moderate quality of evidence to recommend MT plus BMM in the 6–24h time window in patients meeting the eligibility criteria of published randomized trials. These guidelinesdetails aspects of prehospital management, patient selection based on clinical and imaging characteristics, and treatment modalities.ConclusionsMT is the standard of care in patients with LVO-related acute stroke. Appropriate patient selection and timely reperfusion are crucial. Further randomized trials are needed to inform clinical decision-making with regard tothe mothership and drip-and-ship approaches, anesthaesia modalities during MT, and to determine whether MT is beneficial in patients with low stroke severity or large infarct volume.

Published
2019

40. Efficacy of Endovascular Therapy in Acute Ischemic Stroke Depends on Age and Clinical Severity

Author

Raphaël, Le Bouc, Frédéric, Clarençon, Elena, Meseguer, Bertrand, Lapergue, Arturo, Consoli, Guillaume, Turc, Olivier, Naggara, Duc Long, Duong, Jerome, Servan, Peggy, Reiner, Marc Antoine, Labeyrie, Mathieu, Fisselier, Raphaël, Blanc, Wassim, Farhat, Christine, Pires, Mathieu, Zuber, Michael, Obadia, Mikael, Mazighi, Fernando, Pico, Jean-Louis, Mas, Pierre, Amarenco, Yves, Samson, and Sophie, Gerber

Subjects
Male, medicine.medical_specialty, Stroke severity, Ischemia, Severity of Illness Index, Endovascular therapy, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Internal medicine, Humans, Medicine, Clinical severity, Prospective Studies, Registries, 030212 general & internal medicine, Endovascular treatment, Stroke, Acute ischemic stroke, Aged, Aged, 80 and over, Advanced and Specialized Nursing, business.industry, Endovascular Procedures, Age Factors, Middle Aged, medicine.disease, Combined Modality Therapy, Treatment Outcome, Case-Control Studies, Tissue Plasminogen Activator, Cardiology, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, Large vessel occlusion
Abstract

Background and Purpose— Efficacy of endovascular treatment (EVT) for ischemic stroke because of large vessel occlusion may depend on patients’ age and stroke severity; we, therefore, developed a prognosis score based on these variables and examined whether EVT efficacy differs between patients with good, intermediate, or poor prognostic score. Methods— A total of 4079 patients with an acute ischemic stroke were identified from the Paris Stroke Consortium registry. We developed the stroke checkerboard (SC) score (SC score=1 point per decade ≥50 years of age and 2 points per 5 points on the National Institutes of Health Stroke Scale) to predict spontaneous outcome. The primary outcome was the adjusted common odds ratio for an improvement in the modified Rankin Scale at 90 days after EVT, in patients with low, intermediate, or high SC scores. To rule out potential selection biases, a nested case-control analysis, with individual matching for all major prognostic factors, was also performed, to compare patients with large vessel occlusion in the anterior circulation treated or not with EVT. Results— In patients untreated with EVT, SC scores 12 were predictive of poor outcomes (modified Rankin Scale score, 4–6; area under the curve, 0.88). In the overall population, there was an interaction between EVT and prognosis group ( P 12 (common odds ratio, 1.70; 95% confidence interval, 1.13–2.56) and SC scores 8 to 12 (odds ratio, 1.37; 95% confidence interval, 1.11–1.69) but not in patients with SC scores Conclusions— In patients stratified with the SC score, EVT was associated with improved functional outcome in older and more severe patients but not in younger and less severe patients.

Published
2018
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41. Rivaroxaban plasma levels in acute ischemic stroke and intracerebral hemorrhage

Author

Nils Peters, Peter S. Sandor, Guillaume Turc, Marialuisa Zedde, Eivind Berge, Philippe Lyrer, Gian Marco De Marchis, Patrik Michel, Georg Kägi, Andrea Zini, Leo H. Bonati, Christopher Traenka, Sabine Schädelin, Gilles Rodier, Stefan T. Engelter, Susanne Wegener, Ilaria Maestrini, David J. Seiffge, Charlotte Cordonnier, Monika Kapauer, Jochen Vehoff, Gaia Sirimarco, Dimtrios A. Tsakiris, Marcel Arnold, Andreas R. Luft, Alexandros A Polymeris, Sebastian Thilemann, Emmanuel De Maistre, Yannick Béjot, Urs Fischer, David J. Werring, and Manuel Cappellari

Subjects
Intracerebral hemorrhage, medicine.medical_specialty, Rivaroxaban, Neurology, Receiver operating characteristic, business.industry, medicine.medical_treatment, Renal function, Thrombolysis, 030204 cardiovascular system & hematology, medicine.disease, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Cardiology, Medicine, cardiovascular diseases, Neurology (clinical), business, Stroke, 030217 neurology & neurosurgery, medicine.drug, Cohort study
Abstract

OBJECTIVE: Information about Rivaroxaban plasma levels (RivLev) may guide treatment decisions in patients with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) taking rivaroxaban. METHODS: In a multicenter registry-based study (Novel-Oral-Anticoagulants-In-Stroke-Patients collaboration;NOACISP;ClinicalTrials.gov:NCT02353585) of patients with stroke while taking rivaroxaban, we compared RivLev in patients with AIS and ICH. We determined how many AIS-patients had RivLev≤100ng/ml, indicating possible eligibility for thrombolysis and how many ICH-patients had RivLev≥75ng/ml, possibly eligible for the use of specific reversal agents. We explored factors associated with RivLev (Spearman correlation; regression models) and studied the sensitivity and specificity of INR-thresholds to substitute RivLevs using cross tables and ROC curves. RESULTS: Among 241 patients (median age 80 years[IQR73-84], median time-from-onset-to-admission 2 hours[IQR1-4.5hours], median RivLev 89ng/ml[31-194]), 190 had AIS and 51 had ICH. RivLev were similar in AIS-patients (82ng/ml[IQR30-202] and ICH-patients (102ng/ml[IQR 51-165]; p=0.24). Trough RivLev(≤137ng/ml) occurred in 126/190 (66.3%) AIS- and 34/51 (66.7%) ICH-patients. Among AIS-patients, 108/190 (56.8%) had RivLev≤100ng/ml. In ICH-patients 33/51(64.7%) had RivLev≥75ng/ml. RivLev were associated with rivaroxaban dosage, inversely with renal function and time-since-last-intake (each p

Published
2018
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42. First-Line Use of Contact Aspiration or Stent Retriever Thrombectomy for Large Vessel Occlusion Stroke

Author

Anthony S. Kim and Guillaume Turc

Subjects
Advanced and Specialized Nursing, medicine.medical_specialty, business.industry, Cerebral infarction, medicine.medical_treatment, First line, Embolectomy, medicine.disease, Surgery, medicine, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Stroke, Large vessel occlusion, Stent retriever
Published
2019
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43. The PRE-hospital Stroke Treatment Organization

Author

Stephen M. Davis, Heinrich J. Audebert, James C. Grotta, Anne W. Alexandrov, Guillaume Turc, Ken Uchino, Klaus Fassbender, Martin Ebinger, and M. Shazam Hussain

Subjects
Intracerebral hemorrhage, Government, Telemedicine, business.industry, Ambulances, Staffing, Professional communication, 030204 cardiovascular system & hematology, medicine.disease, Stroke, 03 medical and health sciences, 0302 clinical medicine, White paper, Neurology, Acute Disease, medicine, Humans, Organizational structure, cardiovascular diseases, Medical emergency, business, Societies, Medical, 030217 neurology & neurosurgery
Abstract

Background The PRE-hospital Stroke Treatment Organization was formed in 2016 as an international consortium of medical practitioners involved in pre-hospital treatment of patients with acute stroke. Aims PRE-hospital Stroke Treatment Organization’s mission is to improve stroke outcomes by supporting research and advocacy for pre-hospital stroke treatment in Mobile Stroke Units. PRE-hospital Stroke Treatment Organization will provide a platform to enhance collaborative research across the spectrum of acute stroke management in the pre-hospital setting. PRE-hospital Stroke Treatment Organization will also facilitate the appropriate proliferation and distribution of Mobile Stroke Units by providing a forum for professional communication, resource for public education, and stimulus for government, industry, and philanthropic support. Summary of review In this “white paper”, we describe the evidence supporting pre-hospital stroke treatment, progress to date, practical issues such as application in various environments and staffing, planned research initiatives, and organizational structure. Conclusions PRE-hospital Stroke Treatment Organization is not-for-profit, with membership open to anyone involved (or hoping to become involved) in pre-hospital stroke care. PRE-hospital Stroke Treatment Organization has a Steering Committee comprised of members from Europe, U.S., Canada, Australia, and other regions having a Mobile Stroke Unit in operation. PRE-hospital Stroke Treatment Organization convenes satellite meetings for membership at the International Stroke Conference and European Stroke Congress each year to address the PRE-hospital Stroke Treatment Organization mission. The first research collaborations agreed upon are to: (1) develop a list of common data elements to be collected by all Mobile Stroke Unit programs and entered into a common research database, and (2) develop a protocol for investigating the natural history of hyper-acute Intracerebral Hemorrhage.

Published
2017
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44. Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Stroke Thrombolysis

Author

Wataru Kakuda, Kazumi Kimura, H. Rolf Jäger, Jeffrey L. Saver, Gregory W. Albers, Vincent Thijs, Chelsea S. Kidwell, Christian H. Nolte, Marwan El-Koussy, Duncan Wilson, Wakoh Takahashi, David J. Werring, Guillaume Turc, Jean-Claude Baron, Ashkan Shoamanesh, Hebun Erdur, Andreas Charidimou, Simon Jung, Gareth Ambler, Shunya Takizawa, Jan F. Scheitz, Zoe Fox, Min Lou, Heinrich Mattle, Oscar R. Benavente, Solène Moulin, Junya Aoki, Myriam Edjlali-Goujon, Charlotte Cordonnier, Yusuke Moriya, Asma Sallem, Catherine Oppenheim, Shenqiang Yan, and Pascal P. Klinger-Gratz

Subjects
Advanced and Specialized Nursing, Intracerebral hemorrhage, medicine.medical_specialty, business.industry, medicine.medical_treatment, Retrospective cohort study, Thrombolysis, Odds ratio, 030204 cardiovascular system & hematology, medicine.disease, Tissue plasminogen activator, Confidence interval, Surgery, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, medicine, Cardiology, Neurology (clinical), Cerebral amyloid angiopathy, Cardiology and Cardiovascular Medicine, business, Stroke, 030217 neurology & neurosurgery, medicine.drug
Abstract

Background and Purpose— We assessed whether the presence, number, and distribution of cerebral microbleeds (CMBs) on pre-intravenous thrombolysis MRI scans of acute ischemic stroke patients are associated with an increased risk of intracerebral hemorrhage (ICH) or poor functional outcome. Methods— We performed an individual patient data meta-analysis, including prospective and retrospective studies of acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Using multilevel mixed-effects logistic regression, we investigated associations of pre-treatment CMB presence, burden (1, 2–4, ≥5, and >10), and presumed pathogenesis (cerebral amyloid angiopathy defined as strictly lobar CMBs and noncerebral amyloid angiopathy) with symptomatic ICH, parenchymal hematoma (within [parenchymal hemorrhage, PH] and remote from the ischemic area [remote parenchymal hemorrhage, PHr]), and poor 3- to 6-month functional outcome (modified Rankin score >2). Results— In 1973 patients from 8 centers, the crude prevalence of CMBs was 526 of 1973 (26.7%). A total of 77 of 1973 (3.9%) patients experienced symptomatic ICH, 210 of 1806 (11.6%) experienced PH, and 56 of 1720 (3.3%) experienced PHr. In adjusted analyses, patients with CMBs (compared with those without CMBs) had increased risk of PH (odds ratio: 1.50; 95% confidence interval: 1.09–2.07; P =0.013) and PHr (odds ratio: 3.04; 95% confidence interval: 1.73–5.35; P P =0.014), PH ( P =0.013), and PHr ( P 10 CMBs independently predicted poor 3- to 6-month outcome (odds ratio: 1.85; 95% confidence interval: 1.10–3.12; P =0.020; and odds ratio: 3.99; 95% confidence interval: 1.55–10.22; P =0.004, respectively). Conclusions— Increasing CMB burden is associated with increased risk of ICH (including PHr) and poor 3- to 6-month functional outcome after intravenous thrombolysis for acute ischemic stroke.

Published
2017
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45. Abstract 172: Bridging Therapy versus Intravenous Thrombolysis in Minor Stroke With Large Vessel Occlusion. A French Multicentric Observational Study (MINOR-STROKE)

Author

Pierre Seners, Claire Perrin, Guillaume Turc, and on behalf of the Minor-Stroke Collaborators

Subjects
Advanced and Specialized Nursing, medicine.medical_specialty, Bridging (networking), business.industry, medicine.medical_treatment, Minor stroke, Thrombolysis, Endovascular therapy, Internal medicine, Occlusion, Ischemic stroke, Cardiology, Medicine, Observational study, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Large vessel occlusion
Abstract

Introduction: Whether bridging therapy (endovascular therapy [EVT] plus intravenous thrombolysis [IVT]) is superior to IVT alone in minor strokes with large vessel occlusion (LVO) is unknown. Methods: MINOR-STROKE was a multicentric retrospective cohort collecting data of IVT-treated minor strokes (NIHSS≤5) with LVO (ICA, M1 or M2; with central reading) treated with or without additional EVT in 45 French stroke units. Patients immediately intended for additional EVT -including those who eventually did not receive EVT- were analyzed in the bridging group, whereas patients initially intended for IVT alone -including those who eventually received rescue EVT- were analyzed in the IVT group. Propensity-score (inverse probability of treatment weighting) was used to reduce baseline between-groups differences. The primary outcome was excellent outcome defined as mRS 0-1 at 3 month. Results: Overall, 965 patients were included (237 and 728 in the bridging therapy and IVT groups, respectively). The distribution of all baseline clinical and radiological variables across the 2 groups were similar following propensity-score weighting. Compared with IVT alone, bridging therapy was not associated with better excellent outcome (OR=0.99; 95%CI 0.79-1.24; P =0.95), but was associated with higher risks of symptomatic intracranial haemorrhage (OR=2.39; 95%CI 1.51-3.80; P interaction P =0.01) and proximal M1±ICA (OR=3.63; 95%CI 1.94-6.79; P P =0.87) but deleterious for M2±ICA (OR=0.54; 95%CI 0.38-0.75; P P Conclusion: Overall, we observed similar outcomes with bridging therapy or IVT alone in minor strokes with LVO. However, our data suggest benefit of bridging therapy in patients with ICA or proximal M1 occlusion and potential harm through sICH in patients with M2 occlusion. Randomized trials are strongly commended to confirm these results.

Published
2020
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46. Abstract 101: Predictors of Early Neurological Deterioration in Minor Strokes With Large Vessel Occlusion Treated With Intravenous Thrombolysis. A French Multicentric Observational Study (MINOR-STROKE)

Author

Pierre Seners, Guillaume Turc, and Claire Perrin

Subjects
Advanced and Specialized Nursing, medicine.medical_specialty, business.industry, medicine.medical_treatment, Minor stroke, Thrombolysis, Endovascular therapy, Internal medicine, Ischemic stroke, Cardiology, Medicine, Observational study, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Large vessel occlusion
Abstract

Introduction: Whether thrombectomy added on intravenous thrombolysis (IVT), as compared to IVT alone, is beneficial in minor strokes with large vessel occlusion (LVO) is unknown. To identify predictors of early neurological deterioration (END) following IVT alone may help to select the best candidates for additional thrombectomy. Methods: MINOR-STROKE was a multicentric retrospective registry collecting data of IVT-treated minor strokes (NIHSS≤5) with LVO (internal carotid artery [ICA], M1, M2 or basilar artery; with central reading) treated with or without additional thrombectomy in 45 French stroke units. The patients initially intended for IVT alone, including those who eventually received thrombectomy due to END, were included in the present analysis. END was defined as a ≥4 points on NIHSS within 24hrs following admission. Thrombus length was measured centrally either on T2*-MRI, CT (hyperdense middle cerebral artery) or CT-angiography. Results: Overall, 799 patients were included: mean age 69 years, median NIHSS 3, occlusion located in ICA±M1/M2, proximal M1, distal M1, M2, or basilar artery in 20%, 7%, 19%, 50% and 4% of patients, respectively. Thrombus was visible in 78% of patients (median length 9mm, IQR 6-12mm). END occurred in 15% of patients and was associated with poor 3-month functional outcome (mRS>2: 55% vs. 12% of patients with and without END, respectively). Only 15% of ENDs were due to intracranial haemorrhage. In multivariable analysis, a more proximal occlusion site (M2 [reference], distal M1: OR 2.1 [IC95% 1.1-4.1], proximal M1: OR 3.8 [1.6-9.1], ICA±M1/M2: OR 5.0 [2.6-9.6], basilar artery: OR 4.9 [1.1-4.1]; P P =0.036) were independently associated with END. END occurred in 33%, 19%, 14%, 7% and 27% of patients with ICA±M1/M2, M1 proximal, M1 distal, M2 and basilar artery, respectively, and in 8%, 10%, 14% et 23% of patients with thrombus length of Conclusion: Our study suggests that thrombus location and length are strong predictors of END in minor strokes with LVO. This may help to select the best candidates for additional endovascular therapy.

Published
2020
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47. Abstract TP82: Factors Associated With Good Collateral Flow in Acute Stroke Patients With Large Vessel Occlusion

Author

Catherine Oppenheim, Laurence Legrand, Pauline Roca, Guillaume Turc, Jean-Claude Baron, and Pierre Seners

Subjects
Advanced and Specialized Nursing, medicine.medical_specialty, medicine.diagnostic_test, business.industry, Magnetic resonance imaging, Collateral circulation, Collateral flow, Internal medicine, Ischemic stroke, medicine, Cardiology, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Perfusion, Large vessel occlusion, Acute stroke
Abstract

Introduction: Retrograde collateral flow is critical to maintain tissue perfusion despite large vessel occlusion. However, the premorbid factors associated with good collateral flow remain unclear, with substantial discrepancies in the literature. Methods: Patients from the registries of 6 French stroke centres with the following criteria were included: (1) acute stroke with isolated M1 occlusion ( i.e , without tandem occlusion) referred for thrombectomy between May 2015 and March 2017; and (2) baseline brain MRI, including diffusion weighted imaging, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI). A collateral flow map derived from PWI source data was automatically generated, replicating Kim et al’s previously validated method (Ann. Neurol., 2014). Collateral flow was dichotomized into good and poor. The association between good collateral flow and baseline clinical, biological and radiological variables was studied. Results: One hundred and sixteen patients were included, of which 66 (57%) had good collaterals. As expected, the latter patients had lower admission NIHSS (median: 15 vs . 18, P=0.005) and lower baseline DWI lesion volume (median: 7ml vs . 32ml, Pvs . distal) were similar in both groups (123min vs . 118min, P=0.75; 70% vs. 68%, P=0.85, respectively). There was no significant (P>0.05) difference in gender, age, history of hypertension or diabetes, current smoking, baseline blood glucose and use of statins or antiplatelets between the good and poor collaterals groups. Conclusions: Despite the expected association between PWI-derived collateral flow and baseline clinical and radiological stroke severity in our sample of acute M1 occlusions, there was no association with premorbid factors previously found associated in some -but not all- studies. Our findings suggest that collateral flow is predominantly explained by genetic factors.

Published
2020
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48. Abstract TP23: Mortality Risk in Acute Ischemic Stroke Patients With Large Vessel Occlusion Treated With Mechanical Thrombectomy: A Systematic Review and Meta-Analysis

Author

Aristeidis H. Katsanos, Nitin Goyal, Georgios Magoufis, Konark Malhotra, Valeria Caso, Georgios Tsivgoulis, Peter D. Schellinger, Andrei V Alexandrov, Guillaume Turc, Charlotte Cordonnier, Lina Palaiodimou, and Adam S Arthur

Subjects
Advanced and Specialized Nursing, medicine.medical_specialty, business.industry, medicine.disease, Endovascular therapy, Clinical trial, Mechanical thrombectomy, Meta-analysis, Internal medicine, medicine, Cardiology, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Medical therapy, Stroke, Acute ischemic stroke, Large vessel occlusion
Abstract

Introduction: Recent randomized-controlled clinical trials (RCTs) have provided solid evidence that mechanical thrombectomy (MT) coupled with best medical therapy (BMT) improve functional outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) compared to BMT alone. However, they provided inconclusive evidence on the benefit of MT on mortality. Methods: We evaluated the association of MT+BMT compared to BMT with the risk of three-month mortality using aggregate data from all available RCTs. We also sought to identify potential predictors on the mortality risk and performed univariate meta-regression analyses. Results: Our literature search identified 11 eligible RCTs, including a total of 2,460 patients. The pooled rates of 3-month mortality were 15% (95%CI:12-19%) and 19% (95%CI:16-23%), respectively, in the MT+BMT and BMT groups. In the overall analysis MT+BMT was associated with a significantly lower risk for 3-month mortality compared to BMT (Risk Ratio=0.83, 95% confidence interval:0.69-0.99; p=0.04), without heterogeneity across included studies (I 2 =3%,p for Cochran Q=0.41). No evidence of publication bias was present in funnel plot inspection and Egger’s statistical test (p=0.762). In meta-regression analyses no moderating effect on the aforementioned association was detected with patient age (p=0.254), gender (p=0.702), admission systolic blood pressure (p=0.601), admission glucose (p=0.277), onset-to-groin puncture time (p=0.985), administration of intravenous alteplase prior to MT (p=0.804), MT under general anesthesia (p=0.735) and successful reperfusion following MT (p=0.663). Conclusion: Our meta-analysis provides evidence that MT+BMT reduce the risk of three-month mortality compared to BMT alone. This association appears not to be moderated by individual patient or procedural characteristics.

Published
2020
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49. Bridging therapy or IV thrombolysis in minor stroke with large vessel occlusion

Author

Gioia Mione, Pierre Seners, Isabelle Girard Buttaz, Claire Perrin, Guillaume Turc, Ruben Tamazyan, Jean-Claude Baron, Hilde Hénon, Denis Sablot, Bertrand Lapergue, Cécile Preterre, Nadia Laksiri, Ludovic Lucas, Séverine Debiais, Caroline Arquizan, Institut de psychiatrie et neurosciences de Paris (IPNP - U1266 Inserm), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Hôpital Foch [Suresnes], Département de neurologie[Lille], Université de Lille, Droit et Santé-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Centre Hospitalier Régional Universitaire de Tours (CHRU TOURS), Centre Hospitalier Saint Jean de Perpignan, Neurologie - Centre Hospitalier de Valenciennes (CHV), Centre hospitalier Saint-Joseph [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Service de neurologie [Nantes], Université de Nantes (UN)-Centre hospitalier universitaire de Nantes (CHU Nantes)-Hôpital Guillaume-et-René-Laennec [Saint-Herblain], Neurologie, maladies neuro-musculaires [Hôpital de la Timone - APHM], Aix Marseille Université (AMU)-Assistance Publique - Hôpitaux de Marseille (APHM)- Hôpital de la Timone [CHU - APHM] (TIMONE), Service de neurologie [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Département de neurologie [Montpellier], Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Gui de Chauliac [Montpellier]-Université de Montpellier (UM), Hôpital Pellegrin, CHU Bordeaux [Bordeaux]-Groupe hospitalier Pellegrin, MINOR-STROKE collaborators : Achard S, Agius P, Alamowitch S, Arteaga C, Bennani O, Ben Hassen W, Ben Maacha M, Berthezene Y, Boulanger M, Boutet C, Bracard S, Bricout N, Brunel H, Cakmak S, Charron S, Charron V, Chassin O, Clarençon F, Chbicheb M, Consoli A, Cottier JP, Courselle-Arnoux A, Dargazanli C, Denier C, Dereeper O, Derex L, Desal H, Detante O, Duong DL, Fraticelli L, Gazzola S, Garnier P, Grigoras V, Gouttard S, Guedon A, Hattinguais J, Henri C, Klapczynski F, Lamy C, Ledure S, Leys D, Lopez D, Lun F, Lyoubi A, Malbranque A, Marcel S, Louis Mas J, Masson M, Mechtouff L, Mounier-Vehier F, Niclot P, Nighoghossian N, Obadia A, Oppenheim C, Papagiannaki C, Papassin J, Philippeau F, Pico F, Piotin M, Pires C, Rosso C, Samson Y, Serre I, Sibon I, Soize S, Smadja P, Spelle L, Suissa L, Triquenot A, Tuffal A, Vallet AE, Yger M, Zuber M., Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Département de neurologie [Lille], Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Centre Hospitalier Régional Universitaire de Tours (CHRU Tours), Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Gui de Chauliac [CHU Montpellier], Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Université de Montpellier (UM), Hôpital Gui de Chauliac [Montpellier]-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Université Montpellier 1 (UM1)-Université de Montpellier (UM), Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), and Martinez Rico, Clara

Subjects
0301 basic medicine, Male, medicine.medical_specialty, Bridging (networking), medicine.medical_treatment, [SDV]Life Sciences [q-bio], Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Internal medicine, Occlusion, Medicine, Humans, Thrombolytic Therapy, [SDV.NEU] Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Aged, Retrospective Studies, Thrombectomy, Aged, 80 and over, business.industry, Endovascular Procedures, Minor stroke, Retrospective cohort study, Odds ratio, Thrombolysis, Middle Aged, Combined Modality Therapy, Confidence interval, 3. Good health, [SDV] Life Sciences [q-bio], Stroke, 030104 developmental biology, Treatment Outcome, Neurology, Cardiology, Female, [SDV.NEU]Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC], Neurology (clinical), business, 030217 neurology & neurosurgery, Large vessel occlusion
Abstract

OBJECTIVE Whether bridging therapy (intravenous thrombolysis [IVT] followed by endovascular treatment) is superior to IVT alone in minor stroke with large vessel occlusion (LVO) is unknown. METHODS Multicentric retrospective observational study including, in intention-to-treat, consecutive IVT-treated minor strokes (National Institutes of Health Stroke Scale [NIHSS] ≤ 5) with LVO, with or without additional mechanical thrombectomy. Propensity-score (inverse probability of treatment weighting) was used to reduce baseline between-groups differences. The primary outcome was excellent outcome, that is, modified Rankin score 0 to 1 at 3 months follow-up. RESULTS Overall, 598 patients were included (214 and 384 in the bridging therapy and IVT groups, respectively). Following propensity-score weighting, the distribution of baseline clinical and radiological variables was similar across the two patient groups. Compared with IVT alone, bridging therapy was not associated with excellent outcome (odds ratio [OR] = 0.96; 95% confidence interval [CI] = 0.75-1.24; p = 0.76), but was associated with symptomatic intracranial hemorrhage (OR = 3.01; 95% CI = 1.77-5.11; p

Published
2020
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50. Mortality Risk in Acute Ischemic Stroke Patients With Large Vessel Occlusion Treated With Mechanical Thrombectomy

Author

Peter D. Schellinger, Andrei V. Alexandrov, Lina Palaiodimou, Adam S Arthur, Nitin Goyal, Guillaume Turc, Georgios Tsivgoulis, Georgios Magoufis, Konark Malhotra, Aristeidis H. Katsanos, Valeria Caso, and Charlotte Cordonnier

Subjects
medicine.medical_specialty, Systematic Review and Meta‐analysis, business.industry, mortality, Combined Modality Therapy, Risk Assessment, Brain Ischemia, Stroke, Mechanical thrombectomy, Clinical trial, Cerebrovascular Disorders, thrombectomy, Internal medicine, Ischemic stroke, ischemic stroke, medicine, Cardiology, Humans, Cardiology and Cardiovascular Medicine, business, Medical therapy, Acute ischemic stroke, Randomized Controlled Trials as Topic, Large vessel occlusion
Abstract

Background Recent randomized controlled clinical trials have provided solid evidence that mechanical thrombectomy ( MT ) coupled with best medical therapy ( BMT ) improve functional outcomes of acute ischemic stroke patients with large vessel occlusion compared with BMT alone. However, they provided inconclusive evidence on the benefit of MT on mortality. Methods and Results We evaluated the association of MT + BMT compared with BMT with the risk of 3‐month mortality using aggregate data from all available randomized controlled clinical trials. We also sought to identify potential predictors on the mortality risk and performed univariate meta‐regression analyses. Our literature search identified 11 eligible randomized controlled clinical trials, including a total of 2460 patients. The pooled rates of 3‐month mortality were 15% (95% CI :12%–19%) and 19% (95% CI :16%–23%), respectively, in the MT + BMT and BMT groups. In the overall analysis MT + BMT was associated with a significantly lower risk for 3‐month mortality compared with BMT (risk ratio=0.83, 95% CI:0.69–0.99; P =0.04), without heterogeneity across included studies (I 2 =3%, P for Cochran Q=0.41). No evidence of publication bias was present in funnel plot inspection and Egger statistical test ( P =0.762). In meta‐regression analyses no moderating effect on the aforementioned association was detected with patient age ( P =0.254), sex ( P =0.702), admission systolic blood pressure ( P =0.601), admission glucose ( P =0.277), onset‐to‐groin puncture time ( P =0.985), administration of intravenous alteplase before MT ( P =0.804), MT under general anesthesia ( P =0.735), and successful reperfusion following MT ( P =0.663). Conclusions Our meta‐analysis provides evidence that MT + BMT reduces the risk of 3‐month mortality compared with BMT alone. This association appears not to be moderated by individual patient or procedural characteristics.

Published
2019
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