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1. Baseline clinical and neuroradiological predictors of outcome in patients with large ischemic core undergoing mechanical thrombectomy: a retrospective multicenter study

Author

Alexandre, Andrea, Monforte, Mauro, Brunetti, Valerio, Scarcia, Luca, Cirillo, Luigi, Zini, Andrea, Scala, Irene, Nardelli, Vincenzo, Arbia, Francesco, Arbia, Giuseppe, Frisullo, Giovanni, Kalsoum, Erwah, Camilli, Arianna, De Leoni, Davide, Francesca, Colò, Abruzzese, Serena, Piano, Mariangela, Rollo, Claudia, Macera, Antonio, Ruggiero, Maria, Lafe, Elvi, Gabrieli, Joseph Domenico, Cester, Giacomo, Limbucci, Nicola, Arba, Francesco, Ferretti, Simone, Da Ros, Valerio, Bellini, Luigi, Salsano, Giancarlo, Mavilio, Nicola, Russo, Riccardo, Bergui, Mauro, Caragliano, Antonio Armando, Vinci, Sergio Lucio, Romano, Daniele Giuseppe, Frauenfelder, Giulia, Semeraro, Vittorio, Porzia, Ganimede Maria, Lozupone, Emilio, Romi, Andrea, Cavallini, Anna, Milonia, Luca, Muto, Massimo, Candelaresi, Paolo, Calabresi, Paolo, Pedicelli, Alessandro, Broccolini, Aldobrando, Arbia, Giuseppe (ORCID:0000-0001-5173-3931), Calabresi, Paolo (ORCID:0000-0003-0326-5509), Pedicelli, Alessandro (ORCID:0000-0002-2558-8838), Broccolini, Aldobrando (ORCID:0000-0001-8295-9271), Alexandre, Andrea, Monforte, Mauro, Brunetti, Valerio, Scarcia, Luca, Cirillo, Luigi, Zini, Andrea, Scala, Irene, Nardelli, Vincenzo, Arbia, Francesco, Arbia, Giuseppe, Frisullo, Giovanni, Kalsoum, Erwah, Camilli, Arianna, De Leoni, Davide, Francesca, Colò, Abruzzese, Serena, Piano, Mariangela, Rollo, Claudia, Macera, Antonio, Ruggiero, Maria, Lafe, Elvi, Gabrieli, Joseph Domenico, Cester, Giacomo, Limbucci, Nicola, Arba, Francesco, Ferretti, Simone, Da Ros, Valerio, Bellini, Luigi, Salsano, Giancarlo, Mavilio, Nicola, Russo, Riccardo, Bergui, Mauro, Caragliano, Antonio Armando, Vinci, Sergio Lucio, Romano, Daniele Giuseppe, Frauenfelder, Giulia, Semeraro, Vittorio, Porzia, Ganimede Maria, Lozupone, Emilio, Romi, Andrea, Cavallini, Anna, Milonia, Luca, Muto, Massimo, Candelaresi, Paolo, Calabresi, Paolo, Pedicelli, Alessandro, Broccolini, Aldobrando, Arbia, Giuseppe (ORCID:0000-0001-5173-3931), Calabresi, Paolo (ORCID:0000-0003-0326-5509), Pedicelli, Alessandro (ORCID:0000-0002-2558-8838), and Broccolini, Aldobrando (ORCID:0000-0001-8295-9271)

Abstract

Background: Recent randomized trials have shown the benefit of mechanical thrombectomy (MT) also in patients with an established large ischemic core. Aim: The purpose of this study was to define baseline predictors of clinical outcome in patients with large vessel occlusion (LVO) in the anterior circulation and an Alberta Stroke Program Early CT score (ASPECTS) ≤ 5, undergoing MT. Material and methods: The databases of 16 comprehensive stroke centers were retrospectively screened for patients with LVO and ASPECTS ≤ 5 that received MT. Baseline clinical and neuroradiological features, including the differential contribution of all ASPECTS regions to the composite score, were collected. Primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2. Statistical analysis used a logistic regression model and random forest algorithm. Results: 408 patients were available for analysis. In multivariate model, among baseline features, lower age (OR 0.962, 95% CI 0.943-0.982) and lower National Institute of Health Stroke Scale (NIHSS) score (OR 0.911, 95% CI 0.862-0.963) were associated with the mRS score 0-2. Involvement of the M2 (OR 0.398, 95% CI 0.206-0.770) or M4 (OR 0.496, 95% CI 0.260-0.945) ASPECTS regions was associated with an unfavorable outcome. Random forest analysis confirmed that age and baseline NIHSS score are the most important variables influencing clinical outcome, whereas involvement of cortical regions M5, M4, M2 and M1 can have a negative impact. Conclusion: Our retrospective analysis shows that, along with age and baseline clinical impairment, presence of early ischemic changes involving cortical areas has a role in clinical outcome in patients with large ischemic core undergoing MT.

Published
2024

2. Predictors of parenchymal hematoma and clinical outcome after mechanical thrombectomy in patients with large ischemic core due to large vessel occlusion: a retrospective multicenter study

Author

Alexandre, Andrea M, Scarcia, Luca, Brunetti, Valerio, Scala, Irene, Kalsoum, Erwah, Valente, Iacopo, Camilli, Arianna, De Leoni, Davide, Colò, Francesca, Frisullo, Giovanni, Piano, Mariangela, Rollo, Claudia, Macera, Antonio, Ruggiero, Maria, Lafe, Elvi, Gabrieli, Joseph D, Cester, Giacomo, Limbucci, Nicola, Arba, Francesco, Ferretti, Simone, Da Ros, Valerio, Bellini, Luigi, Salsano, Giancarlo, Mavilio, Nicola, Russo, Riccardo, Bergui, Mauro, Caragliano, Antonio A, Vinci, Sergio L, Romano, Daniele G, Frauenfelder, Giulia, Semeraro, Vittorio, Ganimede, Maria P, Lozupone, Emilio, Romi, Andrea, Cavallini, Anna, Milonia, Luca, Muto, Massimo, Giordano, Flavio, Cirillo, Luigi, Calabresi, Paolo, Pedicelli, Alessandro, Broccolini, Aldobrando, Calabresi, Paolo (ORCID:0000-0003-0326-5509), Pedicelli, Alessandro (ORCID:0000-0002-2558-8838), Broccolini, Aldobrando (ORCID:0000-0001-8295-9271), Alexandre, Andrea M, Scarcia, Luca, Brunetti, Valerio, Scala, Irene, Kalsoum, Erwah, Valente, Iacopo, Camilli, Arianna, De Leoni, Davide, Colò, Francesca, Frisullo, Giovanni, Piano, Mariangela, Rollo, Claudia, Macera, Antonio, Ruggiero, Maria, Lafe, Elvi, Gabrieli, Joseph D, Cester, Giacomo, Limbucci, Nicola, Arba, Francesco, Ferretti, Simone, Da Ros, Valerio, Bellini, Luigi, Salsano, Giancarlo, Mavilio, Nicola, Russo, Riccardo, Bergui, Mauro, Caragliano, Antonio A, Vinci, Sergio L, Romano, Daniele G, Frauenfelder, Giulia, Semeraro, Vittorio, Ganimede, Maria P, Lozupone, Emilio, Romi, Andrea, Cavallini, Anna, Milonia, Luca, Muto, Massimo, Giordano, Flavio, Cirillo, Luigi, Calabresi, Paolo, Pedicelli, Alessandro, Broccolini, Aldobrando, Calabresi, Paolo (ORCID:0000-0003-0326-5509), Pedicelli, Alessandro (ORCID:0000-0002-2558-8838), and Broccolini, Aldobrando (ORCID:0000-0001-8295-9271)

Abstract

BackgroundThe aim of our study was to find predictors of parenchymal hematoma (PH) and clinical outcome after mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO) and baseline large infarct.MethodsThe databases of 16 stroke centers were retrospectively screened for patients with anterior circulation LVO and baseline Alberta Stroke Program Early CT Score (ASPECTS) <= 5 that received MT. Procedural parameters, including the number of passes during first and second technique of MT, were recorded. Outcome measures were occurrence of PH type 2 and any type of PH after MT, and the 90-day modified Rankin Scale (mRS) score of 0-3 and 0-2.ResultsIn total, 408 patients were available for analysis. A higher number of passes in the second technique was predictive of PH type 2 (odds ratio (OR) - 3.204, 95% confidence interval (CI) 1.140 to 9.005), whereas procedure conducted under general anesthesia was associated with lower risk (OR 0.127, 95% CI 0.002 to 0.808). The modified thrombolysis in cerebral infarction grade 2c-3 was associated with the mRS score 0-3 (OR 3.373, 95% CI 1.891 to 6.017), whereas occurrence of PH type 2 was predictive of unfavorable outcome (OR 0.221, 95% CI 0.063 to 0.773). Similar results were found for the mRS score 0-2 outcome measure.ConclusionIn patients with large ischemic core, a higher number of passes during MT and procedure not conducted under general anesthesia are associated with increased rate of PH type 2, that negatively impact the clinical outcome. Our data outline a delicate balance between the need of a complete recanalization and the risk of PH following MT.

Published
2023

3. Early neurological deterioration in patients with minor stroke due to isolated M2 occlusion undergoing medical management: a retrospective multicenter study

Author

Broccolini, Aldobrando, Brunetti, Valerio, Colò, Francesca, M Alexandre, Andrea, Valente, Iacopo, Falcou, Anne, Frisullo, Giovanni, Pedicelli, Alessandro, Scarcia, Luca, Scala, Irene, Rizzo, Pier Andrea, Bellavia, Simone, Camilli, Arianna, Milonia, Luca, Piano, Mariangela, Macera, Antonio, Commodaro, Christian, Ruggiero, Maria, Da Ros, Valerio, Bellini, Luigi, A Lazzarotti, Guido, Cosottini, Mirco, A Caragliano, Armando, L Vinci, Sergio, D Gabrieli, Joseph, Causin, Francesco, Panni, Pietro, Roveri, Luisa, Limbucci, Nicola, Arba, Francesco, Pileggi, Marco, Bianco, Giovanni, G Romano, Daniele, Frauenfelder, Giulia, Semeraro, Vittorio, P Ganimede, Maria, Lozupone, Emilio, Fasano, Antonio, Lafe, Elvi, Cavallini, Anna, Russo, Riccardo, Bergui, Mauro, Calabresi, Paolo, Della Marca, Giacomo, Aldobrando Broccolini (ORCID:0000-0001-8295-9271), Valerio Brunetti, Iacopo Valente, Giovanni Frisullo, Alessandro Pedicelli (ORCID:0000-0002-2558-8838), Irene Scala, Pier Andrea Rizzo, Simone Bellavia, Arianna Camilli, Emilio Lozupone, Paolo Calabresi (ORCID:0000-0003-0326-5509), Giacomo Della Marca (ORCID:0000-0001-6914-799X), Broccolini, Aldobrando, Brunetti, Valerio, Colò, Francesca, M Alexandre, Andrea, Valente, Iacopo, Falcou, Anne, Frisullo, Giovanni, Pedicelli, Alessandro, Scarcia, Luca, Scala, Irene, Rizzo, Pier Andrea, Bellavia, Simone, Camilli, Arianna, Milonia, Luca, Piano, Mariangela, Macera, Antonio, Commodaro, Christian, Ruggiero, Maria, Da Ros, Valerio, Bellini, Luigi, A Lazzarotti, Guido, Cosottini, Mirco, A Caragliano, Armando, L Vinci, Sergio, D Gabrieli, Joseph, Causin, Francesco, Panni, Pietro, Roveri, Luisa, Limbucci, Nicola, Arba, Francesco, Pileggi, Marco, Bianco, Giovanni, G Romano, Daniele, Frauenfelder, Giulia, Semeraro, Vittorio, P Ganimede, Maria, Lozupone, Emilio, Fasano, Antonio, Lafe, Elvi, Cavallini, Anna, Russo, Riccardo, Bergui, Mauro, Calabresi, Paolo, Della Marca, Giacomo, Aldobrando Broccolini (ORCID:0000-0001-8295-9271), Valerio Brunetti, Iacopo Valente, Giovanni Frisullo, Alessandro Pedicelli (ORCID:0000-0002-2558-8838), Irene Scala, Pier Andrea Rizzo, Simone Bellavia, Arianna Camilli, Emilio Lozupone, Paolo Calabresi (ORCID:0000-0003-0326-5509), and Giacomo Della Marca (ORCID:0000-0001-6914-799X)

Abstract

Background: Patients with minor stroke and M2 occlusion undergoing best medical management (BMM) may face early neurological deterioration (END) that can lead to poor long-term outcome. In case of END, rescue mechanical thrombectomy (rMT) seems beneficial. Our study aimed to define factors relevant to clinical outcome in patients undergoing BMM with the possibility of rMT on END, and find predictors of END. Methods: Patients with M2 occlusion and a baseline National Institutes of Health Stroke Scale (NIHSS) score≤5 that received either BMM only or rMT on END after BMM were extracted from the databases of 16 comprehensive stroke centers. Clinical outcome measures were a 90-day modified Rankin Scale (mRS) score of 0-1 or 0-2, and occurrence of END. Results: Among 10 169 consecutive patients with large vessel occlusion admitted between 2016 and 2021, 208 patients were available for analysis. END was reported in 87 patients that were therefore all subjected to rMT. In a logistic regression model, END (OR 3.386, 95% CI 1.428 to 8.032), baseline NIHSS score (OR 1.362, 95% CI 1.004 to 1.848) and a pre-event mRS score=1 (OR 3.226, 95% CI 1.229 to 8.465) were associated with unfavorable outcome. In patients with END, successful rMT was associated with favorable outcome (OR 4.549, 95% CI 1.098 to 18.851). Among baseline clinical and neuroradiological features, presence of atrial fibrillation was a predictor of END (OR 3.547, 95% CI 1.014 to 12.406). Conclusion: Patients with minor stroke due to M2 occlusion and atrial fibrillation should be closely monitored for possible worsening during BMM and, in this case, promptly considered for rMT.

Published
2022

4. Mechanical thrombectomy in minor stroke due to isolated M2 occlusion: a multicenter retrospective matched analysis

Author

Alexandre, Andrea M, Colò, Francesca, Brunetti, Valerio, Valente, Iacopo, Frisullo, Giovanni, Pedicelli, Alessandro, Scarcia, Luca, Rollo, Claudia, Falcou, Anne, Milonia, Luca, Andrighetti, Marco, Piano, Mariangela, Macera, Antonio, Commodaro, Christian, Ruggiero, Maria, Da Ros, Valerio, Bellini, Luigi, Lazzarotti, Guido A, Cosottini, Mirco, Caragliano, Armando A, Vinci, Sergio L, Gabrieli, Joseph D, Causin, Francesco, Panni, Pietro, Roveri, Luisa, Limbucci, Nicola, Arba, Francesco, Pileggi, Marco, Bianco, Giovanni, Romano, Daniele G, Diana, Francesco, Semeraro, Vittorio, Burdi, Nicola, Ganimede, Maria P, Lozupone, Emilio, Fasano, Antonio, Lafe, Elvi, Cavallini, Anna, Russo, Riccardo, Bergui, Mauro, Calabresi, Paolo, Della Marca, Giacomo, Broccolini, Aldobrando, Pedicelli, Alessandro (ORCID:0000-0002-2558-8838), Calabresi, Paolo (ORCID:0000-0003-0326-5509), Della Marca, Giacomo (ORCID:0000-0001-6914-799X), Broccolini, Aldobrando (ORCID:0000-0001-8295-9271), Alexandre, Andrea M, Colò, Francesca, Brunetti, Valerio, Valente, Iacopo, Frisullo, Giovanni, Pedicelli, Alessandro, Scarcia, Luca, Rollo, Claudia, Falcou, Anne, Milonia, Luca, Andrighetti, Marco, Piano, Mariangela, Macera, Antonio, Commodaro, Christian, Ruggiero, Maria, Da Ros, Valerio, Bellini, Luigi, Lazzarotti, Guido A, Cosottini, Mirco, Caragliano, Armando A, Vinci, Sergio L, Gabrieli, Joseph D, Causin, Francesco, Panni, Pietro, Roveri, Luisa, Limbucci, Nicola, Arba, Francesco, Pileggi, Marco, Bianco, Giovanni, Romano, Daniele G, Diana, Francesco, Semeraro, Vittorio, Burdi, Nicola, Ganimede, Maria P, Lozupone, Emilio, Fasano, Antonio, Lafe, Elvi, Cavallini, Anna, Russo, Riccardo, Bergui, Mauro, Calabresi, Paolo, Della Marca, Giacomo, Broccolini, Aldobrando, Pedicelli, Alessandro (ORCID:0000-0002-2558-8838), Calabresi, Paolo (ORCID:0000-0003-0326-5509), Della Marca, Giacomo (ORCID:0000-0001-6914-799X), and Broccolini, Aldobrando (ORCID:0000-0001-8295-9271)

Abstract

Background The purpose of this study was to evaluate the effectiveness of mechanical thrombectomy (MT) in patients with isolated M2 occlusion and minor symptoms and identify possible baseline predictors of clinical outcome. Methods The databases of 16 high-volume stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institutes of Health Stroke Scale (NIHSS) score <= 5 who received either early MT (eMT) or best medical management (BMM) with the possibility of rescue MT (rMT) on early neurological worsening. Because our patients were not randomized, we used propensity score matching (PSM) to estimate the treatment effect of eMT compared with the BMM/rMT. The primary clinical outcome measure was a 90-day modified Rankin Scale score of 0-1. Results 388 patients were initially selected and, after PSM, 100 pairs of patients receiving eMT or BMM/rMT were available for analysis. We found no significant differences in clinical outcome and in safety measures between patients receiving eMT or BMM/rMT. Similar results were also observed after comparison between eMT and rMT. Concerning baseline predicting factors of outcome, the involvement of the M2 inferior branch was associated with a favorable outcome. Conclusion Our multicenter retrospective analysis has shown no benefit of eMT in minor stroke patients with isolated M2 occlusion over a more conservative therapeutic approach. Although our results must be viewed with caution, in these patients it appears reasonable to consider BMM as the first option and rMT in the presence of early neurological deterioration.

Published
2022

5. Pediatric Moyamoya Disease and Syndrome in Italy: A Multicenter Cohort

Author

Po', Chiara, Nosadini, Margherita, Zedde, Marialuisa, Pascarella, Rosario, Mirone, Giuseppe, Cicala, Domenico, Rosati, Anna, Cosi, Alessandra, Toldo, Irene, Colombatti, Raffaella, Martelli, Paola, Iodice, Alessandro, Accorsi, Patrizia, Giordano, Lucio, Savasta, Salvatore, Foiadelli, Thomas, Sanfilippo, Giuseppina, Lafe, Elvis, Thyrion, Federico Zappoli, Polonara, Gabriele, Campa, Serena, Raviglione, Federico, Scelsa, Barbara, Bova, Stefania Maria, Greco, Filippo, Cordelli, Duccio Maria, Cirillo, Luigi, Toni, Francesco, Baro, Valentina, Causin, Francesco, Frigo, Anna Chiara, Suppiej, Agnese, Sainati, Laura, Azzolina, Danila, Agostini, Manuela, Cesaroni, Elisabetta, De Carlo, Luigi, Di Rosa, Gabriella, Esposito, Giacomo, Grazian, Luisa, Morini, Giovanna, Nicita, Francesco, Operto, Francesca Felicia, Pruna, Dario, Ragazzi, Paola, Rollo, Massimo, Spalice, Alberto, Striano, Pasquale, Skabar, Aldo, Lanterna, Luigi Alberto, Carai, Andrea, Marras, Carlo Efisio, Manara, Renzo, Sartori, Stefano, Po', Chiara, Nosadini, Margherita, Zedde, Marialuisa, Pascarella, Rosario, Mirone, Giuseppe, Cicala, Domenico, Rosati, Anna, Cosi, Alessandra, Toldo, Irene, Colombatti, Raffaella, Martelli, Paola, Iodice, Alessandro, Accorsi, Patrizia, Giordano, Lucio, Savasta, Salvatore, Foiadelli, Thoma, Sanfilippo, Giuseppina, Lafe, Elvi, Thyrion, Federico Zappoli, Polonara, Gabriele, Campa, Serena, Raviglione, Federico, Scelsa, Barbara, Bova, Stefania Maria, Greco, Filippo, Cordelli, Duccio Maria, Cirillo, Luigi, Toni, Francesco, Baro, Valentina, Causin, Francesco, Frigo, Anna Chiara, Suppiej, Agnese, Sainati, Laura, Azzolina, Danila, Agostini, Manuela, Cesaroni, Elisabetta, De Carlo, Luigi, Di Rosa, Gabriella, Esposito, Giacomo, Grazian, Luisa, Morini, Giovanna, Nicita, Francesco, Operto, Francesca Felicia, Pruna, Dario, Ragazzi, Paola, Rollo, Massimo, Spalice, Alberto, Striano, Pasquale, Skabar, Aldo, Lanterna, Luigi Alberto, Carai, Andrea, Marras, Carlo Efisio, Manara, Renzo, and Sartori, Stefano

Subjects
arteriopathy, indirect revascularization, aspirin, moyamoya, cerebrovascular event, transient ischemic attack, Pediatrics, Perinatology and Child Health, cerebrovascular events, headache, stroke, NO
Abstract

BackgroundMoyamoya is a rare progressive cerebral arteriopathy, occurring as an isolated phenomenon (moyamoya disease, MMD) or associated with other conditions (moyamoya syndrome, MMS), responsible for 6–10% of all childhood strokes and transient ischemic attacks (TIAs).MethodsWe conducted a retrospective multicenter study on pediatric-onset MMD/MMS in Italy in order to characterize disease presentation, course, management, neuroradiology, and outcome in a European country.ResultsA total of 65 patients (34/65 women) with MMD (27/65) or MMS (38/65) were included. About 18% (12/65) of patients were asymptomatic and diagnosed incidentally during investigations performed for an underlying condition (incMMS), whereas 82% (53/65) of patients with MMD or MMS were diagnosed due to the presence of neurological symptoms (symptMMD/MMS). Of these latter, before diagnosis, 66% (43/65) of patients suffered from cerebrovascular events with or without other manifestations (ischemic stroke 42%, 27/65; TIA 32%, 21/65; and no hemorrhagic strokes), 18% (12/65) of them reported headache (in 4/12 headache was not associated with any other manifestation), and 26% (17/65) of them experienced multiple phenotypes (≥2 among: stroke/TIA/seizures/headache/others). Neuroradiology disclosed ≥1 ischemic lesion in 67% (39/58) of patients and posterior circulation involvement in 51% (30/58) of them. About 73% (47/64) of patients underwent surgery, and 69% (45/65) of them received aspirin, but after diagnosis, further stroke events occurred in 20% (12/61) of them, including operated patients (11%, 5/47). Between symptom onset and last follow-up, the overall patient/year incidence of stroke was 10.26% (IC 95% 7.58–13.88%). At last follow-up (median 4 years after diagnosis, range 0.5–15), 43% (26/61) of patients had motor deficits, 31% (19/61) of them had intellectual disability, 13% (8/61) of them had epilepsy, 11% (7/61) of them had behavioral problems, and 25% (13/52) of them had mRS > 2. The proportion of final mRS > 2 was significantly higher in patients with symptMMD/MMS than in patients with incMMS (p = 0.021). Onset age p = 0.0010 and p = 0.0071, respectively) and mRS > 2 at follow-up (p = 0.0106 and p = 0.0009, respectively).ConclusionsMoyamoya is a severe condition that may affect young children and frequently cause cerebrovascular events throughout the disease course, but may also manifest with multiple and non-cerebrovascular clinical phenotypes including headache (isolated or associated with other manifestations), seizures, and movement disorder. Younger onset age and stroke before diagnosis may associate with increased risk of worse outcome (final mRS > 2).

Published
2022

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