Endovascular Clot Retrieval by Hub-and-Spoke Service Delivery is Feasible Compared with Direct-to-Mothership

2018 ◽  
Vol 46 (3-4) ◽  
pp. 170-175 ◽  
Author(s):  
Penelope van Veenendaal ◽  
Bernard Yan ◽  
Leonid Churilov ◽  
Richard Dowling ◽  
Steven Bush ◽  
...  
Keyword(s):  
Service Delivery ◽  
Clinical Outcomes ◽  
Artery Occlusion ◽  
Large Artery ◽  
Service Model ◽  
Good Clinical Outcome ◽  
Hub And Spoke ◽  
Significant Difference ◽  
The Difference ◽  
Regional Hospitals

Background: Endovascular clot retrieval (ECR) improves outcomes for acute ischaemic stroke with large artery occlusion. However, the provision of ECR requires resource-intensive comprehensive stroke centres (CSC), which are impractical to establish in regional hospitals. An alternative is a “hub-and-spoke” model, whereby ischaemic strokes are triaged at the regional primary centres and where eligible, transferred to a CSC. We aimed to compare the outcomes of patients directly admitted to a CSC with patients treated in the “hub-and-spoke” model. We hypothesize that there are no significant differences in clinical outcomes between the 2 systems. Methods: We included patients undergoing ECR at a CSC. Patients were categorised into 2 groups; the first group included patients directly admitted to the CSC and the second group included patients in the “hub-and-spoke” model. Good clinical outcome was defined as modified Rankin Scale 0–2 and the difference between the 2 groups was tested by logistic regression. Results: Of 178 patients, 50 (28%) presented directly to CSC and 128 (72%) were transferred from a referring hospital. The median age was 70 (interquartile range 58–77) and 61% were male. Thrombolysis in ischaemic cerebral-infarction 2b/3 recanalisation was achieved in 79% of patients. Of the direct group, 63% (95% CI 48–77%) achieved good clinical outcomes compared to 52% (95% CI 43–61%) in the “hub-and-spoke” group (p = 0.233). Conclusion: This state-wide service model demonstrates comparable clinical outcomes to that described in clinical trials. We found no significant difference in outcome between patients directly admitted to CSC and those with “hub-and-spoke” service delivery.

scholarly journals Procedural and clinical outcomes of endovascular recanalization therapy in patients with cancer-related stroke

2018 ◽  
Vol 24 (5) ◽  
pp. 520-528 ◽  
Author(s):  
Seunguk Jung ◽  
Cheolkyu Jung ◽  
Jae Hyoung Kim ◽  
Byung Se Choi ◽  
Yun Jung Bae ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Independent Predictor ◽  
Metastatic Cancer ◽  
Cryptogenic Stroke ◽  
Artery Occlusion ◽  
Large Artery ◽  
Stroke Patients ◽  
Patients With Cancer ◽  
Endovascular Recanalization ◽  
Significant Difference

Objective Embolism due to coagulopathy might be the main pathomechanism underlying cancer-related stroke (CRS). CRS patients with a large artery occlusion could be candidates for endovascular recanalization therapy (ERT), although its procedural and clinical outcomes are not well known. This study aimed to investigate the procedural and clinical outcomes of ERT in CRS patients and the characteristics associated with outcomes compared with those of conventional stroke patients. Methods A registry of consecutive acute ischemic stroke patients who underwent ERT between January 2011 and October 2015 was retrospectively reviewed. CRS patients are described as those who had (a) cryptogenic stroke with advanced or metastatic cancer; (b) no other possible causes of stroke such as cardioembolism (CE) and large artery atherosclerosis (LAA); and (c) elevated D-dimer levels or diffusion-restricted lesions in multiple vascular territories. We compared procedural and clinical outcomes at discharge among CRS, CE, and LAA patients. Results A total of 329 patients were finally enrolled in this study; of these, 19 were CRS patients. The rate of successful recanalization, defined as modified treatment in cerebral infarction grade 2b or 3, was lower in the CRS group than in the LAA and CE groups (63% versus 84% versus 84%, p = .06). CRS subtype was an independent predictor for successful recanalization after ERT in the multivariate analysis (odds ratio, 0.317; 95% confidence interval, 0.116–0.867; p < .001). No significant difference in the rate of good clinical outcomes at discharge was observed among groups. Conclusions Although clinical outcomes at discharge were similar for CE and LAA patients, complete recanalization seemed more difficult to achieve in CRS patients than in conventional stroke patients.

scholarly journals Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke

2021 ◽  
Vol 11 (4) ◽  
pp. 504
Author(s):  
Dalibor Sila ◽  
Markus Lenski ◽  
Maria Vojtková ◽  
Mustafa Elgharbawy ◽  
František Charvát ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Binary Logistic Regression ◽  
Stent Retriever ◽  
Good Clinical Outcome ◽  
Significant Difference ◽  
Aspiration Technique

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

scholarly journals Identification and Characterization of Unique Subgroups of Chronic Pain Individuals with Dispositional Personality Traits

2016 ◽  
Vol 2016 ◽  
pp. 1-7 ◽  
Author(s):  
S. Mehta ◽  
D. Rice ◽  
A. McIntyre ◽  
H. Getty ◽  
M. Speechley ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Personality Traits ◽  
Clinical Outcomes ◽  
High Risk Group ◽  
Comprehensive Treatment ◽  
Cluster Membership ◽  
Significant Difference ◽  
Secondary Objective ◽  
The Difference ◽  
And Coping

Objective.The current study attempted to identify and characterize distinct CP subgroups based on their level of dispositional personality traits. The secondary objective was to compare the difference among the subgroups in mood, coping, and disability.Methods.Individuals with chronic pain were assessed for demographic, psychosocial, and personality measures. A two-step cluster analysis was conducted in order to identify distinct subgroups of patients based on their level of personality traits. Differences in clinical outcomes were compared using the multivariate analysis of variance based on cluster membership.Results.In 229 participants, three clusters were formed. No significant difference was seen among the clusters on patient demographic factors including age, sex, relationship status, duration of pain, and pain intensity. Those with high levels of dispositional personality traits had greater levels of mood impairment compared to the other two groups (p<0.05). Significant difference in disability was seen between the subgroups.Conclusions.The study identified a high risk group of CP individuals whose level of personality traits significantly correlated with impaired mood and coping. Use of pharmacological treatment alone may not be successful in improving clinical outcomes among these individuals. Instead, a more comprehensive treatment involving psychological treatments may be important in managing the personality traits that interfere with recovery.

scholarly journals Mechanical Thrombectomy in Stroke. Experience from Switching from Stent Retriever Only to Stent Retriever Combined with Aspiration Catheter

2021 ◽  
Vol 10 (9) ◽  
pp. 1802
Author(s):  
Grzegorz Meder ◽  
Paweł Żuchowski ◽  
Wojciech Skura ◽  
Violetta Palacz-Duda ◽  
Milena Świtońska ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Statistical Significance ◽  
Stent Retriever ◽  
Single Center Experience ◽  
Significant Difference ◽  
First Pass ◽  
Need To Evaluate ◽  
The Difference

Endovascular treatment is a rapidly evolving technique; therefore, there is a constant need to evaluate this method and its modifications. This paper discusses a single-center experience and the results of switching from the stent retriever only (SO) mechanical thrombectomy (MT) to the combined approach (CA), with a stent retriever and aspiration catheters. Methods: The study involved a retrospective analysis of 70 patients undergoing MT with the use of either SO or CA. The primary endpoint was the frequency of perfect reperfusion defined as grade 3 of the modified Thrombolysis in Cerebral Infarction scale (mTICI) after the first pass. The secondary endpoints were the procedure success, defined as mTICI grades 2b-3; time of the procedure; clinical outcome, measured by 90 days’ modified Rankin Scale (mRS) score; Δ NIHSS, defined as the difference between National Institutes of Health Stroke Scale (NIHSS) score at patients’ admission and discharge; and the total number of device passes. Results: Out of the 70 patients included, 33 were treated with SO and 37 with CA. In both groups, a total number of 42 patients received intravenous recombined tissue plasminogen activator (iv-rTPA: 20 patients (60.6%) in the SO group and 22 patients (59.5%) in the CA group (p = 1.000). There was a significant difference between the groups regarding first-pass success rate, with 46% in the CA group and 18% in the SO group, (OR 3.83, 95% CI 1.28 to 11.44, p = 0.016). Complete procedure success tended to be more frequent in the CA group than in the SO group—94.6% vs. 84.8% (OR 3.13, 95% CI 0.56 to 17.34, p = 0.193)—and CA tended to require a lower number of passes than SO (mean 1.76 vs. 2.09 passes per procedure, p = 0.114), yet these differences did not reach statistical significance. Mean duration of the procedure was significantly shorter in the CA group than in the SO group (49 min vs. 64 min, p = 0.017). There was a significant difference in clinical outcomes, with higher Δ NIHSS (9.3 in the CA group vs. 6.7 in the SO group, p = 0.025) after the procedure and 90-day mRS (median 2 in the CA group vs. 4 in the SO group, p = 0.031). Conclusions: Combining stent retrievers with aspiration catheters may offer a beneficial effect on angiographic results and clinical outcomes in stroke patients undergoing endovascular treatment.

scholarly journals Should syndesmotic screws be removed or retained? A meta-analysis

2020 ◽  
Author(s):  
Wanjin Qin ◽  
Peng Yang ◽  
Nanning Lv ◽  
Kaiwen Chen ◽  
Huilin Yang ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Meta Analysis ◽  
Controlled Trials ◽  
Cochrane Central Register ◽  
Search Terms ◽  
Central Register ◽  
Significant Difference ◽  
The Difference ◽  
Mean Differences ◽  
American Orthopaedic

Abstract Background The aim of this study was to evaluate the different clinical outcomes after removing or retaining syndesmotic screws, and the difference in clinical outcomes after retaining broken or loose syndesmotic screws was also evaluated. Methods A systematic literature search was performed using PubMed, Web of Science, EMBASE and the Cochrane Central Register of Controlled Trials. In this meta-analysis, we conducted online searches using the search terms “syndesmotic diastasis”, “syndesmotic injury”, “syndesmotic screw”, “syndesmotic fixation”, and “tibiofibular syndesmosis”. The analysis was performed on individual patient data from all the studies that met the selection criteria. Clinical outcomes were expressed as standard mean differences for continuous outcomes with 95% confidence intervals. Heterogeneity was assessed using the Chi 2 test and the I 2 statistic. Results There were 2 randomized controlled trials (RCTs) and 6 observational articles included in this analysis. In the comparison between retained and removed screws and the comparison between broken or loose and removed screws, no significant difference was found in terms of visual analogue scale (VAS), Olerud-Molander Ankle Score (OMAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score. Broken or loose screws were associated with better AOFAS scores compared with removed or intact screws, and no significant difference was found in terms of VAS and OMAS scores. Conclusions According to our analysis, there was no significant difference in clinical outcomes between removed and retained screws. Broken or loose screws were not associated with bad functional outcomes and may even lead to better function compared with removed or retained screws.

scholarly journals Characteristics, management and response to alteplase in China versus non-China participants of the ENCHANTED trial

2017 ◽  
Vol 2 (2) ◽  
pp. 53-58 ◽  
Author(s):  
Lily Song ◽  
Xia Wang ◽  
Thompson Robinson ◽  
Richard I Lindley ◽  
Hisatomi Arima ◽  
...  
Keyword(s):  
Low Dose ◽  
Standard Dose ◽  
Artery Occlusion ◽  
Lipid Lowering ◽  
Large Artery ◽  
Stroke Study ◽  
Significant Difference ◽  
Scale Scores ◽  
Management Factors ◽  
Artery Disease

BackgroundThe characteristics of patients with acute ischaemic stroke (AIS) and their management vary across regions, which may influence outcomes. We examined for differential patterns of outcome between China and non-China participants of the ENhanced Control of Hypertension And Thrombolysis strokE stuDy (ENCHANTED), which tested different alteplase doses in AIS.MethodsENCHANTED was an international, multicentre, open, blinded-endpoint trial of the effects of low-dose (0.6 mg/kg) versus standard-dose (0.9 mg/kg) intravenous alteplase on 90-day disability outcomes and symptomatic intracerebral haemorrhage (sICH) in 3310 patients with AIS.ResultsParticipants (n=1419, 48%) in China were younger, and more often male, hypertensive and with prior stroke and coronary artery disease, but less likely to have atrial fibrillation and use antihypertensive, antithrombotic and lipid-lowering agents, compared with non-China patients with AIS. Although China participants had more AIS due to large artery occlusion, were treated later and had differing ancillary management, there was no significant difference in 90-day modified Rankin scale scores 2–6 (55.6% vs 47.8%; OR, adjusted for baseline and management factors 0.87 (95% CI 0.71 to 1.07; p=0.20)) and risk of sICH (Safe Implementation of Thrombolysis in Stroke-Monitoring Study criteria: 1.4% vs 1.8%; p=0.12) compared with non-China participants. There was no heterogeneity in the treatment effects of low-dose versus standard-dose alteplase between China and non-China participants.ConclusionPatients with AIS recruited to the ENCHANTED trial in China had similar outcomes in response to thrombolysis treatment despite significantly differing demographic, clinical and management factors to patients with AIS in other regions.

scholarly journals Magnitude of Blood Pressure Change and Clinical Outcomes after Thrombectomy in Stroke Caused by Large Artery Occlusion

2021 ◽  
Author(s):  
Mohammad Anadani ◽  
Marius Matusevicius ◽  
Georgios Tsivgoulis ◽  
André Peeters ◽  
Ana Paiva Nunes ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Clinical Outcomes ◽  
Pressure Change ◽  
Artery Occlusion ◽  
Blood Pressure Change ◽  
Large Artery

Abstract WP439: Who Benefits From CT-Angiography Previous Intravenous Thrombolysis?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Pedro Cardona ◽  
Helena Quesada ◽  
Blanca Lara ◽  
Nuria Cayuela ◽  
Paloma Mora ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Clinical Group ◽  
Large Artery ◽  
Characteristic Analysis ◽  
Vessel Occlusion ◽  
Significant Difference ◽  
Distal Migration

Background: Endovascular treatment (EVT) is an effective treatment in strokes with persistent large artery occlusion despite previous intravenous thrombolisis (IVT) as rescue treatment. Performing computer tomography angiography (CTA) before IVT could allow early activation of neurointerventional teams; however routine CTA could delay unnecessary door-to-needle time of IVT and may be infeasible. Methods: We reviewed stroke code activations between May 2011 and June 2015 in our comprehensive stroke center and divided into groups based on NIHSS and patency of arterial occlusion according to non-enhanced CT on admission (dense artery sign or dot sign) and baseline CTA. We assessed patients treated with IVT and selected to EVT according to results in CTA post-IVT. We analyze percentage of recanalization or migration of thrombus after IVT alone and variables associated to successful treatment. Results: Of 2856 stroke codes registered during the study period 1810 were diagnosis of ischemic strokes. We treated 520 patients with IVT, 202 had a radiological evidence of large artery occlusion (55%M1, 32% M2, 5%TICA, 5%ICA, 3% basilar). Thirty-two percent of patients showed changes in CTA carried out after IVT(17% successfully recanalized, 15% distal migration of thrombus) so they were not selected to endovascular treatment. There were significant difference between M1 and M2 occlusion regarding changes in CTA after IVT (23% vs 70%; p<0.001). In multivariate logistic regression a baseline score NIH<10 was associated with higher percentage of recanalization with rtPA despite signs of large vessel occlusion (78% vs 32%; p:0.001). In receiver operating characteristic analysis higher baseline NIH was associated with persistent occlusion after IVT (area under curve=0.79;95% CI, 0.6-0.9; P:0.001) with optima threshold of 10 ( Sensivity 84%, Specificity 74%). Conclusions: We consider defer CTA angiography until after IVT in stroke code patients with moderate clinical impairment (NIH<10) or M2-segment occlusion, because they achieve a high percentage of arterial recanalization. CTA previous IVT could be unnecessary, provide unreliable information and delay IVT in that clinical group but could be useful to plan EVT in patients with higher NIH scores.

Abstract TMP7: Blood Pressure Goal Post Mechanical Yhrombectomy for Anterior and Posterior Circulation Stroke: A Multicenter Registry Study

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ming Yang ◽  
Xiaochuan Huo ◽  
Ning Ma ◽  
Feng Gao ◽  
Dapeng Mo ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Clinical Outcomes ◽  
Functional Independence ◽  
Artery Occlusion ◽  
Posterior Circulation ◽  
Blood Pressure Goal ◽  
Large Artery ◽  
Registry Study ◽  
Anterior Circulation ◽  
Posterior Circulation Stroke

Background and Purpose: The effect of blood pressure (BP) within 24 hours post-mechanical thrombectomy (MT) accounts on clinical outcomes for patients with successful reperfusion. We aimed to investigate the relationship between BP during 24 hours post-MT with clinical outcomes individually for anterior circulation stroke (ACS) or posterior circulation stroke (PCS) patients Method: Patients with successful recanalization and a full record of systolic BP (SBP) and diastolic BP (DBP) every two hours within 24 hours post-MT were included from the ANGEL study, a multi-centric, prospective registry study of endovascular treatment owing to proximal large-artery occlusion from June 2015 to December 2017. We divided patients into three groups based on maximum SBP: <140 (intensive), 140-160 (moderate) and <180 mmHg (permissive). Clinical outcomes included functional independence (modified Rankin Scale score 0-2), mortality at 90 days follow up and intracerebral hemorrhage (ICH). Results: 355 eligible patients were enrolled in this study. There were 162, 124, and 69 patients in the intensive, moderate, and permissive group, respectively. A 10mmHg increase of maximum SBP during the first 24 hours post-MT was independently associated with a lower likelihood of functional independence (OR=0.84 [0.75-0.94], p=0.001) at 90 days after adjusting for potential confounders. As to ACS, intensive SBP management was associated with higher odds of 90-day functional independence (OR=0.38 [0.18-0.79], p=0.010), compared with permissive SBP group. As to PCS, moderate SBP management was associated with lower odds of 90-day mortality, either compared with permissive or intensive SBP group. Conclusion: Higher maximum SBP post-MT was independently associated with a higher risk of poor clinical outcomes. Intensive SBP control may be more reasonable for patients with ACS, while moderate SBP is more beneficial for PCS. Although more randomized trials are needed.

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