Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window: A Pooled Analysis of Patient-Level Data

Stroke ◽  
2021 ◽  
Author(s):  
Ashutosh P. Jadhav ◽  
Mayank Goyal ◽  
Johanna Ospel ◽  
Bruce C. Campbell ◽  
Charles B.L.M. Majoie ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Time Window ◽  
Early Time ◽  
Computed Tomography Perfusion ◽  
Patient Level Data ◽  
Patient Level ◽  
Good Functional Outcome ◽  
Level Data

Background and Purpose: The optimal imaging paradigm for endovascular thrombectomy (EVT) patient selection in early time window (0–6 hours) treated acute ischemic stroke patients remains uncertain. We aimed to compare post-EVT outcomes between patients who underwent prerandomization basic (noncontrast computed tomography [CT], CT angiography only) versus additional advanced imaging (computed tomography perfusion [CTP] imaging) and to determine the association of performance of prerandomization CTP imaging with clinical outcomes. Methods: The HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) pooled patient-level data from randomized controlled trials comparing EVT with usual care for acute ischemic stroke due to anterior circulation large vessel occlusion. Good functional outcome, defined as modified Rankin Scale score 0 to 2 at 90 days, was compared between randomized patients with and without CTP baseline imaging. Univariable and multivariable binary logistic regression analysis was performed to determine the association of baseline CTP imaging and good functional outcome. Results: We analyzed 1348 patients 610 (45.3%) of whom underwent CTP prerandomization. The benefit of EVT compared with best medical management was maintained irrespective of the baseline imaging paradigm (90-day modified Rankin Scale score 0–2 in EVT versus control patients: with CTP: 46.0% (137/298) versus 28.9% (88/305), without CTP: 44.1% (162/367) versus 27.3% (100/366). Performance of CTP baseline imaging compared with baseline noncontrast CT and CT angiography only yielded similar rates of good outcome (odds ratio, 1.05 [95% CI, 0.82–1.33], adjusted odds ratio, 1.04, [95% CI, 0.80–1.35]). Conclusions: Rates of good functional outcome were similar among patients in whom CTP was or was not performed, and EVT treatment effect in the 0- to 6-hour time window was similar in patients with and without baseline CTP imaging.

scholarly journals Multiple Subpial Transections for Medically Refractory Epilepsy: A Disaggregated Review of Patient-Level Data

Neurosurgery ◽  
2017 ◽  
Vol 82 (5) ◽  
pp. 613-620 ◽  
Author(s):  
John D Rolston ◽  
Hansen Deng ◽  
Doris D Wang ◽  
Dario J Englot ◽  
Edward F Chang
Keyword(s):  
Confidence Interval ◽  
Odds Ratio ◽  
Refractory Epilepsy ◽  
Seizure Type ◽  
Seizure Outcome ◽  
Seizure Freedom ◽  
Patient Level Data ◽  
Patient Demographics ◽  
Patient Level ◽  
Level Data

Abstract BACKGROUND Multiple subpial transections (MST) are a treatment for seizure foci in nonresectable eloquent areas. OBJECTIVE To systematically review patient-level data regarding MST. METHODS Studies describing patient-level data for MST procedures were extracted from the Medline and PubMed databases, yielding a synthetic cohort of 212 patients from 34 studies. Data regarding seizure outcome, patient demographics, seizure type, surgery type, and complications were extracted and analyzed. RESULTS Seizure freedom was achieved in 55.2% of patients undergoing MST combined with resection, and 23.9% of patients undergoing MST alone. Significant predictors for seizure freedom were a temporal lobe focus (odds ratio 4.9; 95% confidence interval 1.71, 14.3) and resection of portions of the focus, when feasible (odds ratio 3.88; 95% confidence interval 2.02, 7.45). Complications were frequent, with transient mono- or hemiparesis affecting 19.8% of patients, transient dysphasia 12.3%, and permanent paresis or dysphasia in 6.6% and 1.9% of patients, respectively. CONCLUSION MST is an effective treatment for refractory epilepsy in eloquent cortex, with greater chances of seizure freedom when portions of the focus are resected in tandem with MST. The reported rates of seizure freedom with MST are higher than those of existing neuromodulatory therapies, such as vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation, though these latter therapies are supported by randomized-controlled trials, while MST is not. The reported complication rate of MST is higher than that of resection and neuromodulatory therapies. MST remains a viable option for the treatment of eloquent foci, provided a careful risk-benefit analysis is conducted.

Bortezomib-Based Versus Nonbortezomib-Based Induction Treatment Before Autologous Stem-Cell Transplantation in Patients With Previously Untreated Multiple Myeloma: A Meta-Analysis of Phase III Randomized, Controlled Trials

2013 ◽  
Vol 31 (26) ◽  
pp. 3279-3287 ◽  
Author(s):  
Pieter Sonneveld ◽  
Hartmut Goldschmidt ◽  
Laura Rosiñol ◽  
Joan Bladé ◽  
Juan José Lahuerta ◽  
...  
Keyword(s):  
Peripheral Neuropathy ◽  
Odds Ratio ◽  
Phase Iii ◽  
Integrated Analysis ◽  
Induction Treatment ◽  
Efficacy And Safety ◽  
Post Transplantation ◽  
Patient Level Data ◽  
Patient Level ◽  
Level Data

Purpose To characterize efficacy and safety of bortezomib-based versus nonbortezomib-based induction regimens through an integrated analysis of data from phase III studies in transplantation-eligible patients with previously untreated myeloma. Patients and Methods Patient-level data from the IFM 2005-01 (bortezomib-dexamethasone v vincristine-doxorubicin-dexamethasone [VAD] induction), HOVON-65/GMMG-HD4 (bortezomib-doxorubicin-dexamethasone v VAD), and PETHEMA GEM05MENOS65 (bortezomib-thalidomide-dexamethasone v thalidomide-dexamethasone) studies were pooled in an integrated analysis of efficacy and safety. Study-level data from the GIMEMA MM-BO2005 study (bortezomib-thalidomide-dexamethasone v thalidomide-dexamethasone) supplemented the integrated patient-level analysis. Key efficacy end points were post-transplantation complete plus near-complete response (CR+nCR) rate and progression-free survival (PFS). Results Patient-level data for 1,572 patients (bortezomib-based induction, n = 787; nonbortezomib-based induction, n = 785) were included. Post-transplantation CR+nCR rate was significantly higher following bortezomib-based versus nonbortezomib-based induction (38% v 24%; odds ratio, 2.05; P < .001); the benefit remained similar (pooled odds ratio, 1.96) when GIMEMA MM-BO2005 data were included. Median PFS was 35.9 months versus 28.6 months with bortezomib-based versus nonbortezomib-based induction, respectively (hazard ratio, 0.75; P < .001); 3-year overall survival (OS) rates were 79.7% and 74.7%, respectively (hazard ratio for OS, 0.81; P = .0402). Median duration of induction treatment was 11 weeks in both treatment groups. Rates of peripheral neuropathy during induction were 34% versus 17% (grade ≥ 3, 6% v 1%). Overall, 3% and 4% of patients died during bortezomib-based and nonbortezomib-based induction, respectively. Conclusion Bortezomib-based induction results in significant improvements in response and PFS/OS compared with nonbortezomib-based induction and is generally well tolerated, with a higher rate of peripheral neuropathy but no apparent increase in risk of death during induction.

scholarly journals Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke

2018 ◽  
Vol 7 (6) ◽  
pp. 513-521 ◽  
Author(s):  
Nuno Martins ◽  
Ana Aires ◽  
Beatriz Mendez ◽  
Sandra Boned ◽  
Marta Rubiera ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Cerebral Blood Volume ◽  
Time Window ◽  
Infarct Volume ◽  
Early Time ◽  
Infarct Core ◽  
Computed Tomography Perfusion ◽  
Noncontrast Ct ◽  
Adjusted Logistic Regression ◽  
Core Volume

Background: Determining the size of infarct extent is crucial to elect patients for reperfusion therapies. Computed tomography perfusion (CTP) based on cerebral blood volume may overestimate infarct core on admission and consequently include ghost infarct core (GIC) in a definitive lesional area. Purpose: Our goal was to confirm and better characterize the GIC phenomenon using CTP cerebral blood flow (CBF) as the reference parameter to determine infarct core. Methods: We performed a retrospective, single-center analysis of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions considering noncontrast CT Alberta Stroke Program Early CT Score ≥6 in patients with pretreatment CTP. We used the RAPID® software to measure admission infarct core based on initial CBF. The final infarct was extracted from follow-up CT. GIC was defined as initial core minus final infarct > 10 mL. Results: A total of 123 patients were included. The median National Institutes of Health Stroke Scale score was 18 (13–20), the median time from symptoms to CTP was 188 (67–288) min, and the recanalization rate (Thrombolysis in Cerebral Infarction score 2b, 2c, or 3) was 83%. Twenty patients (16%) presented with GIC. GIC was associated with shorter time to recanalization (150 [105–291] vs. 255 [163–367] min, p = 0.05) and larger initial CBF core volume (38 [26–59] vs. 6 [0–27] mL, p < 0.001). An adjusted logistic regression model identified time to recanalization < 302 min (OR 4.598, 95% CI 1.143–18.495, p = 0.032) and initial infarct volume (OR 1.01, 95% CI 1.001–1.019, p = 0.032) as independent predictors of GIC. At 24 h, clinical improvement was more frequent in patients with GIC (80 vs. 49%, p = 0.01). Conclusions: CTP CBF < 30% may overestimate infarct core volume, especially in patients imaged in the very early time window and with fast complete reperfusion. Therefore, the CTP CBF technique may exclude patients who would benefit from endovascular treatment.

scholarly journals Time Matters

Stroke ◽  
2020 ◽  
Vol 51 (6) ◽  
pp. 1766-1771 ◽  
Author(s):  
Manuel Requena ◽  
Marta Olivé ◽  
Álvaro García-Tornel ◽  
Noelia Rodríguez-Villatoro ◽  
Matías Deck ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Functional Outcome ◽  
Scale Score ◽  
Odds Ratio ◽  
Hemorrhagic Transformation ◽  
National Institutes Of Health ◽  
Retrospective Case ◽  
Good Functional Outcome ◽  
Angiography Suite

Background and Purpose— Direct transfer to angiography-suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The magnitude of the improvement of good outcome rates in function of time depends of several factors. We aim to analyze the benefit of DTAS according to time from symptom onset. Methods— Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to computed tomography (directly transferred to computed tomography) from February 2016 to June 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline National Institutes of Health Stroke Scale score (±2 points), and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (modified Rankin Scale score, 0–2) and safety variables stratified in less or more than 3 hours from onset to arrive. Results— There were no significant differences regarding age, sex, or baseline National Institutes of Health Stroke Scale score. Median door-to-groin time was shorter in the DTAS patients (16 [3–21] minutes versus 70 [41.5–98.5]; P <0.01). DTAS patients presented lower National Institutes of Health Stroke Scale score at 24 hours (9 [3.5–17] versus 14 [5–19]; P =0.01) and a lower rate of symptomatic hemorrhagic transformation (4.6% versus 10.9%, P <0.03). At 90 days, DTAS patients had a higher rate of good functional outcome (43% versus 29%; odds ratio, 1.81 [95% CI, 1.14–2.87]; P =0.01). Better outcome in DTAS was observed in patients admitted in the 0 to 3 hours form onset window (n=156, odds ratio 2.63 [95% CI, 1.31–5.28]; P <0.01), but not in patients admitted in the 3 to 6 hours window (n=193, odds ratio, 1.37 [95% CI, 0.72–2.60]; P =0.2). Conclusions— DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.

scholarly journals Amalgamation of cloud-based colonoscopy videos with patient-level metadata to facilitate large-scale machine learning

2021 ◽  
Vol 09 (02) ◽  
pp. E233-E238
Author(s):  
Rajesh N. Keswani ◽  
Daniel Byrd ◽  
Florencia Garcia Vicente ◽  
J. Alex Heller ◽  
Matthew Klug ◽  
...  
Keyword(s):  
Machine Learning ◽  
Large Scale ◽  
Medical Center ◽  
Academic Medical Center ◽  
Procedure Time ◽  
Image Capture ◽  
Common Procedure ◽  
Patient Level Data ◽  
Patient Level ◽  
Level Data

Abstract Background and study aims Storage of full-length endoscopic procedures is becoming increasingly popular. To facilitate large-scale machine learning (ML) focused on clinical outcomes, these videos must be merged with the patient-level data in the electronic health record (EHR). Our aim was to present a method of accurately linking patient-level EHR data with cloud stored colonoscopy videos. Methods This study was conducted at a single academic medical center. Most procedure videos are automatically uploaded to the cloud server but are identified only by procedure time and procedure room. We developed and then tested an algorithm to match recorded videos with corresponding exams in the EHR based upon procedure time and room and subsequently extract frames of interest. Results Among 28,611 total colonoscopies performed over the study period, 21,170 colonoscopy videos in 20,420 unique patients (54.2 % male, median age 58) were matched to EHR data. Of 100 randomly sampled videos, appropriate matching was manually confirmed in all. In total, these videos represented 489,721 minutes of colonoscopy performed by 50 endoscopists (median 214 colonoscopies per endoscopist). The most common procedure indications were polyp screening (47.3 %), surveillance (28.9 %) and inflammatory bowel disease (9.4 %). From these videos, we extracted procedure highlights (identified by image capture; mean 8.5 per colonoscopy) and surrounding frames. Conclusions We report the successful merging of a large database of endoscopy videos stored with limited identifiers to rich patient-level data in a highly accurate manner. This technique facilitates the development of ML algorithms based upon relevant patient outcomes.

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