Exploring the relationship between ischemic core volume and clinical outcomes after thrombectomy or thrombolysis

Neurology ◽  
2019 ◽  
Vol 93 (3) ◽  
pp. e283-e292 ◽  
Author(s):  
Chushuang Chen ◽  
Mark W. Parsons ◽  
Christopher R. Levi ◽  
Neil J. Spratt ◽  
Ferdinand Miteff ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Clinical Outcomes ◽  
Odds Ratio ◽  
Clinical Severity ◽  
Lesion Volume ◽  
Lower Odds ◽  
Excellent Outcome ◽  
Ischemic Core ◽  
Core Volume ◽  
Excellent Clinical Outcome

ObjectiveTo assess whether complete reperfusion after IV thrombolysis (IVT-R) would result in similar clinical outcomes compared to complete reperfusion after endovascular thrombectomy (EVT-R) in patients with a large vessel occlusion (LVO).MethodsEVT-R patients were matched by age, clinical severity, occlusion location, and baseline perfusion lesion volume to IVT-R patients from the International Stroke Perfusion Imaging Registry (INSPIRE). Only patients with complete reperfusion on follow-up imaging were included. The excellent clinical outcome rates at day 90 on the modified Rankin Scale (mRS) were compared between EVT-R vs IVT-R patients within quintiles of increasing baseline ischemic core and penumbral volumes.ResultsFrom INSPIRE, there were 141 EVT-R patients and 141 matched controls (IVT-R) who met the eligibility criteria. In patients with a baseline core <30 mL, EVT-R resulted in a lower odds of achieving an excellent outcome at day 90 compared to IVT-R (day 90 mRS 0–1 odds ratio 0.01, p < 0.001). The group with a baseline core <30 mL contained mostly patients with distal M1 or M2 occlusions, and good collaterals (p = 0.01). In patients with a baseline ischemic core volume >30 mL (internal carotid artery and mostly proximal M1 occlusions), EVT-R increased the odds of patients achieving an excellent clinical outcome (day 90 mRS 0–1 odds ratio 1.61, p < 0.001) and there was increased symptomatic intracranial hemorrhage in the IVT-R group with core >30 mL (20% vs 3% in EVT-R, p = 0.008).ConclusionFrom this observational cohort, LVO patients with larger baseline ischemic cores and proximal LVO, with poorer collaterals, clearly benefited from EVT-R compared to IVT-R alone. However, for distal LVO patients, with smaller ischemic cores and better collaterals, EVT-R was associated with a lower odds of favorable outcome compared to IVT-R alone.

scholarly journals e-ASPECTS derived acute ischemic volumes on non-contrast-enhanced computed tomography images

2019 ◽  
Vol 15 (9) ◽  
pp. 995-1001
Author(s):  
Simon Nagel ◽  
Olivier Joly ◽  
Johannes Pfaff ◽  
Panagiotis Papanagiotou ◽  
Klaus Fassbender ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Clinical Outcome ◽  
Diffusion Weighted Imaging ◽  
Clinical Severity ◽  
Stroke Severity ◽  
Lesion Volume ◽  
Computed Tomography Perfusion ◽  
Computed Tomography Images ◽  
Diffusion Weighted ◽  
Ischemic Core

Background and purpose Validation of automatically derived acute ischemic volumes (AAIV) from e-ASPECTS on non-contrast computed tomography (NCCT). Materials and methods Data from three studies were reanalyzed with e-ASPECTS Version 7. AAIV was calculated in milliliters (ml) in all scored ASPECTS regions of the hemisphere detected by e-ASPECTS. The National Institute of Health Stroke Scale (NIHSS) determined stroke severity at baseline and clinical outcome was measured with the modified Rankin Scale (mRS) between 45 and 120 days. Spearman ranked correlation coefficients (R) of AAIV and e-ASPECTS scores with NIHSS and mRS as well as Pearson correlation of AAIV with diffusion-weighted imaging and CT perfusion-estimated ischemic “core” volumes were calculated. Multivariate regression analysis (odds ratio, OR with 95% confidence intervals, CI) and Bland–Altman plots were performed. Results We included 388 patients. Mean AAIV was 11.6 ± 18.9 ml and e-ASPECTS was 9 (8–10: median and interquartile range). AAIV, respectively e-ASPECTS correlated with NIHSS at baseline (R = 0.35, p < 0.001; R = −0.36, p < 0.001) and follow-up mRS (R = 0.29, p < 0.001; R = −0.3, p < 0.001). In subsets of patients, AAIV correlated strongly with diffusion-weighted imaging ( n = 37, R = 0.68, p < 0.001) and computed tomography perfusion-derived ischemic “core” ( n = 41, R = 0.76, p < 0.001) lesion volume and Bland–Altman plots showed a bias close to zero (−2.65 ml for diffusion-weighted imaging and 0.45 ml forcomputed tomography perfusion “core”). Within the whole cohort, the AAIV (OR 0.98 per ml, 95% CI 0.96–0.99) and e-ASPECTS scores (OR 1.3, 95%CI 1.07–1.57) were independent predictors of good outcome Conclusion AAIV on NCCT correlated moderately with clinical severity but strongly with diffusion-weighted imaging lesion and computed tomography perfusion ischemic “core” volumes and predicted clinical outcome.

scholarly journals Thrombolysis Improves Reperfusion and the Clinical Outcome in Tandem Occlusion Stroke Related to Cervical Dissection: TITAN and ETIS Pooled Analysis

2021 ◽  
Vol 23 (3) ◽  
pp. 411-419
Author(s):  
Gaultier Marnat ◽  
Igor Sibon ◽  
Romain Bourcier ◽  
Mohammad Anadani ◽  
Florent Gariel ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Pooled Analysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Excellent Outcome ◽  
Shift Analysis ◽  
Tandem Occlusion ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose Despite the widespread adoption of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke (LVOS) in the anterior circulation, the optimal strategy for the treatment tandem occlusion related to cervical internal carotid artery (ICA) dissection is still debated. This individual patient pooled analysis investigated the safety and efficacy of prior intravenous thrombolysis (IVT) in anterior circulation tandem occlusion related to cervical ICA dissection treated with MT.Methods We performed a retrospective analysis of two merged prospective multicenter international real-world observational registries: Endovascular Treatment in Ischemic Stroke (ETIS) and Thrombectomy In TANdem occlusions (TITAN) registries. Data from MT performed in the treatment of tandem LVOS related to cervical ICA dissection between January 2012 and December 2019 at 24 comprehensive stroke centers were analyzed. The primary endpoint was a favorable outcome defined as 90-day modified Rankin Scale (mRS) score of 0–2.Results The study included 144 patients with tandem occlusion LVOS due to cervical ICA dissection, of whom 94 (65.3%) received IVT before MT. Prior IVT was significantly associated with a better clinical outcome considering the mRS shift analysis (common odds ratio, 2.59; 95% confidence interval [CI], 1.35 to 4.93; P=0.004 for a 1-point improvement) and excellent outcome (90-day mRS 0–1) (adjusted odds ratio [aOR], 4.23; 95% CI, 1.60 to 11.18). IVT was also associated with a higher rate of intracranial successful reperfusion (83.0% vs. 64.0%; aOR, 2.70; 95% CI, 1.21 to 6.03) and a lower rate of symptomatic intracranial hemorrhage (4.3% vs. 14.8%; aOR, 0.21; 95% CI, 0.05 to 0.80).Conclusions Prior IVT before MT for the treatment of tandem occlusion related to cervical ICA dissection was safe and associated with an improved 90-day functional outcome.

scholarly journals Noncontrast Computed Tomography e-Stroke Infarct Volume Is Similar to RAPID Computed Tomography Perfusion in Estimating Postreperfusion Infarct Volumes

Stroke ◽  
2021 ◽  
Vol 52 (2) ◽  
pp. 634-641 ◽  
Author(s):  
Mehdi Bouslama ◽  
Krishnan Ravindran ◽  
George Harston ◽  
Gabriel M. Rodrigues ◽  
Leonardo Pisani ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Odds Ratio ◽  
Functional Outcomes ◽  
Adjusted Odds Ratio ◽  
Infarct Volume ◽  
Tertiary Care ◽  
Computed Tomography Perfusion ◽  
Ischemic Core ◽  
Noncontrast Computed Tomography ◽  
Core Volume

Background and Purpose: The e-Stroke Suite software (Brainomix, Oxford, United Kingdom) is a tool designed for the automated quantification of The Alberta Stroke Program Early CT Score and ischemic core volumes on noncontrast computed tomography (NCCT). We sought to compare the prediction of postreperfusion infarct volumes and the clinical outcomes across NCCT e-Stroke software versus RAPID (IschemaView, Menlo Park, CA) computed tomography perfusion measurements. Methods: All consecutive patients with anterior circulation large vessel occlusion stroke presenting at a tertiary care center between September 2010 and November 2018 who had available baseline infarct volumes on both NCCT e-Stroke Suite software and RAPID CTP as well as final infarct volume (FIV) measurements and achieved complete reperfusion (modified Thrombolysis in Cerebral Infarction scale 2c-3) post-thrombectomy were included. The associations between estimated baseline ischemic core volumes and FIV as well as 90-day functional outcomes were assessed. Results: Four hundred seventy-nine patients met inclusion criteria. Median age was 64 years (55–75), median e-Stroke and computed tomography perfusion ischemic core volumes were 38.4 (21.8–58) and 5 (0–17.7) mL, respectively, whereas median FIV was 22.2 (9.1–56.2) mL. The correlation between e-Stroke and CTP ischemic core volumes was moderate (R=0.44; P <0.001). Similarly, moderate correlations were observed between e-Stroke software ischemic core and FIV (R=0.52; P <0.001) and CTP core and FIV (R=0.43; P <0.001). Subgroup analysis showed that e-Stroke software and CTP performance was similar in the early and late (>6 hours) treatment windows. Multivariate analysis showed that both e-Stroke software NCCT baseline ischemic core volume (adjusted odds ratio, 0.98 [95% CI, 0.97–0.99]) and RAPID CTP ischemic core volume (adjusted odds ratio, 0.98 [95% CI, 0.97–0.99]) were independently and comparably associated with good outcome (modified Rankin Scale score of 0–2) at 90 days. Conclusions: NCCT e-Stroke Suite software performed similarly to RAPID CTP in assessing postreperfusion FIV and functional outcomes for both early- and late-presenting patients. NCCT e-Stroke volumes seems to represent a viable alternative in centers where access to advanced imaging is limited. Moreover, the future development of fusion maps of NCCT and CTP ischemic core estimates may improve upon the current performance of these tools as applied in isolation.

Abstract 1122‐000167: Hyperintense Acute Reperfusion Marker and Hemorrhagic Conversion in Stroke Patients Undergoing Mechanical Reperfusion

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Pouria Moshayedi ◽  
Hamidreza Saber ◽  
David S Liebeskind ◽  
Jeffrey Gornbein ◽  
Bryan Yoo ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
White Matter ◽  
Clinical Outcome ◽  
Blood Brain Barrier ◽  
Brain Barrier ◽  
Periventricular White Matter ◽  
Vessel Occlusion ◽  
Blood Brain ◽  
Ischemic Core ◽  
Core Volume

Introduction : Endovascular thrombectomy (EVT) is a highly effective treatment to improve clinical outcome in patients with acute ischemic stroke due to large vessel occlusion (AIS‐LVO). However, blood‐brain barrier (BBB) disruption causing hemorrhagic transformation and reperfusion injury can potentially negate the beneficial effect of reperfusion. Studying determinants, frequency, and outcomes of the hyperintense acute reperfusion marker (HARM) sign, a biomarker of BBB disruption, would help to identify individual patients at increased risk, as well as developing therapies to prevent BBB breakdown. Methods : In consecutive AIS‐LVO patients with AIS‐LVO who underwent EVT followed by MRI within the next 24 hours, we evaluated frequency, determinants, and outcomes of HARM sign. Results : Among 81 patients meeting study criteria, age was 71.0 (SD 19.7), 58% female, mean NIHSS was 14.5 (SD 6.8), and time from last known well to treatment was 355 min (IQR 206.5 ‐ 664). HARM sign was observed in 64% (52/81) of patients. On multivariate logistic analysis, presence of HARM sign was independently associated with greater periventricular white matter hyperintensity, higher pre‐EVT ischemic core volume, more proximal target vessel occlusion, and achievement of successful reperfusion or better. Hemorrhagic conversion was seen in 31.8% of patients with HARM sign and 26.7% of patients without HARM sign. Multivariate analysis identified higher blood glucose, lower ASPECT, score and greater post‐EVT ischemic core volume as independent predictors of hemorrhagic conversion. HARM sign was identified to correlate with poor clinical outcome in bivariate analysis, but multivariate analysis only identified less neurological deficits, lower baseline systolic BP, lower degree of periventricular white matter hyperintensities, shorter time to device deployment and reduced post EVT ischemic core volume as independent predictors of good clinical outcome (mRS 0–2) upon discharge. Conclusions : The HARM sign indicating disruption of the blood‐brain barrier following EVT is common, present in about 6 of every 10 treated patients. Independent risk factors for HARM sign are chronic ischemic microangiopathy, greater acute ischemic core, and successful reperfusion. HARM sign presence is associated with worse functional outcome.

scholarly journals Influence of Penumbral Reperfusion on Clinical Outcome Depends on Baseline Ischemic Core Volume

Stroke ◽  
2017 ◽  
Vol 48 (10) ◽  
pp. 2739-2745 ◽  
Author(s):  
Chushuang Chen ◽  
Mark W. Parsons ◽  
Matthew Clapham ◽  
Christopher Oldmeadow ◽  
Christopher R. Levi ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Ischemic Core ◽  
Core Volume

Abstract P378: Automated Estimation of Ischemic Core Volume on Non-Contrast-Enhanced Computed Tomography via Machine Learning

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
IRIS E CHEN ◽  
Brian Tsui ◽  
Joe X Qiao ◽  
William Hsu ◽  
Latisha K Sharma ◽  
...  
Keyword(s):  
Machine Learning ◽  
Diffusion Mri ◽  
Pearson Correlation ◽  
Accurate Estimation ◽  
Lesion Volume ◽  
Reference Standard ◽  
Ischemic Lesion ◽  
The Mean ◽  
Ischemic Core ◽  
Core Volume

Background and Purpose: Accurate estimation of ischemic core on baseline imaging has treatment implications in patients with acute ischemic stroke (AIS). Machine learning (ML) algorithms have shown promising results in estimating ischemic core using routine non-contrast CT (NCCT). We used a ML-trained algorithm to quantify ischemic core volume on NCCT and compared the results to concurrent diffusion MRI as the reference standard in patients with AIS. Methods: We analyzed consecutive anterior circulation AIS patients who had baseline (pretreatment) NCCT and MRI (DWI). Ischemic lesion volume was calculated on MRI-DWI using an automated software (Olea Medical SAS, La Ciotat, France). An automatic segmentation approach using a combination of traditional 3D graphics and statistical methods, and ML classification techniques (Brainomix, Oxford, United Kingdom) was used to identify ischemic core voxels on NCCT. Total ischemic core volumes on ML-NCCT and DWI-MR were quantitatively compared by Bland-Altman plots and Pearson correlation. Results: A total of 50 patients (27 female, 23 male, mean age 72.6 years) were included. Baseline imaging was performed within 173 ± 143 minutes (mean ± SD) from symptom onset. The mean time difference between MRI and NCCT was 72 min. The baseline NIHSS was 14, 8-21 (Median, IQR). Algorithm-segmented ischemic core volume detected on NCCT was median 12.7 mL, IQR 3.5-26.0 mL. Ischemic core volume on DWI MRI was median 8.8 mL, IQR 3.2-34.0 mL. ML-NCCT core volumes significantly correlated with DWI MRI core volumes, r =0.61, p <0.001. The mean difference between the ML-NCCT and DWI MRI core volumes was 12.4 mL, p =0.81. For the reperfusion treatment threshold of an ischemic core volume within 70 mL, while no patients would have been excluded using our algorithm, five patients would have been incorrectly dichotomized as having an ischemic volume of <70 mL compared to MRI. Conclusion: This ML-approach accurately quantifies ischemic core volume on NCCT compared to the reference standard of diffusion MRI in patients with AIS.

scholarly journals Ischemic lesion growth in acute stroke: Water uptake quantification distinguishes between edema and tissue infarct

2019 ◽  
Vol 40 (4) ◽  
pp. 823-832 ◽  
Author(s):  
Gabriel Broocks ◽  
Uta Hanning ◽  
Tobias D Faizy ◽  
Alexandra Scheibel ◽  
Jawed Nawabi ◽  
...  
Keyword(s):  
Water Uptake ◽  
Treatment Effects ◽  
Vasogenic Edema ◽  
Outcome Variable ◽  
Lesion Volume ◽  
Ischemic Lesion ◽  
Lesion Growth ◽  
The Mean ◽  
Ischemic Core ◽  
Core Volume

Infarct growth from the early ischemic core to the total infarct lesion volume (LV) is often used as an outcome variable of treatment effects, but can be overestimated due to vasogenic edema. The purpose of this study was (1) to assess two components of early lesion growth by distinguishing between water uptake and true net infarct growth and (2) to investigate potential treatment effects on edema-corrected net lesion growth. Sixty-two M1-MCA-stroke patients with acute multimodal and follow-up CT (FCT) were included. Ischemic lesion growth was calculated by subtracting the initial CTP-derived ischemic core volume from the LV in the FCT. To determine edema-corrected net lesion growth, net water uptake of the ischemic lesion on FCT was quantified and subtracted from the volume of uncorrected lesion growth. The mean lesion growth without edema correction was 20.4 mL (95% CI: 8.2–32.5 mL). The mean net lesion growth after edema correction was 7.3 mL (95% CI: −2.1–16.7 mL; p < 0.0001). Lesion growth was significantly overestimated due to ischemic edema when determined in early-FCT imaging. In 18 patients, LV was lower than the initial ischemic core volume by CTP. These apparently “reversible” core lesions were more likely in patients with shorter times from symptom onset to imaging and higher recanalization rates.

3150Predictors as exercise intolerance and myocardial fibrosis of clinical outcomes in patients with hypertrophic cardiomyopathy

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J W Hwang ◽  
S.U.N.G.M Kim ◽  
S.U.N.G.-J Park ◽  
E U N K Kim ◽  
S.U.N.G.-A Chang ◽  
...  
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
Clinical Outcome ◽  
Clinical Outcomes ◽  
Myocardial Fibrosis ◽  
Left Ventricular ◽  
Clinical Severity ◽  
Exercise Intolerance ◽  
Volume Index ◽  
Cerebral Stroke ◽  
Peak Vo2

Abstract Reduced exercise capacity is common in patients with hypertrophic cardiomyopathy (HCMP), affecting patients along a broad spectrum of clinical severity. Replacement fibrosis is associated with worse outcomes in patients with HCMP. The aim of study was to evaluate cardiopulmonary exercise test (CPET) and cardiac magnetic resonance (CMR) to predict clinical outcomes in HCMP patients. We enrolled 371 patients with HCMP and normal left ventricular (LV) systolic function (ejection fraction >50%), who underwent both CPET and CMR. CMR at 1.5 T, including late gadolinium delayed enhancement (LGE), was carried out to define the amount of myocardial fibrosis. The primary outcome was hard events including cardiac death, myocardial infarction, cardiac transplantation, sustained ventricular tachycardia, cerebral stroke, and heart failure requiring hospitalization. During follow-up (6.1±2.6 years), there were 74 hard events. The patients were older (56.11±10.37 vs. 52.19±11.17, p=0.006) in the group with hard events. Exercise intolerance as peak oxygen consumption (peak VO2) showed in the group with hard events (25.60±6.01 vs. 30.18±6.81, p<0.001). In addition, the amount of myocardial fibrosis as LGE was larger (27.67±23.07 vs. 18.09±15.80, p=0.001). Larger left atrium size as volume index (LAVI) (50.01±18.14 vs. 41.55±16.48, p<0.001), increased LV filling pressure as E/e' (13.80±5.43 vs. 11.50±4.48, p=0.001) and higher level of NT-proBNP in laboratory finding (941.01±895.22 vs. 575.68±910.76, p=0.003) were showed in the group with hard events. Multivariable Cox-proportional analysis with adjustment as age and gender showed that peak VO2 [hazard ratio (HR) = 0.926, 95% confidence interval (CI) 0.872–0.984, p=0.013], LGE (HR=1.022, 95% CI 1.000–1.055, p=0.05) and LAVI (HR=1.03, 95% CI 1.007–1.053, p=0.009) could predict the clinical outcome as hard events. The incremental prognostic value for the prediction of hard events of peak VO2, LGE and LAVI over clinical variables was from 0.759 to 0.772 as the value of area under the curves (AUC). This study demonstrated that the exercise intolerance, progression of myocardial fibrosis, and abnormal diastolic parameters could be significant predictors of clinical outcome in the patients with HCMP. CPET and CMR may help us to monitor and manage cardiac events in these patients. Acknowledgement/Funding None

scholarly journals Be-careful! Behind the storm of severe COVID-19, could be hidden macrophage activation syndrome. A case report with excellent outcome.

2020 ◽  
Author(s):  
Rafaela Silva Guimarães Gonçalves ◽  
André da Costa Victor ◽  
Ana Carolina Oliveira Cavalcanti Tavare ◽  
Angela Luzia Branco Pinto Duarte
Keyword(s):  
Case Report ◽  
Early Diagnosis ◽  
Clinical Outcome ◽  
Macrophage Activation Syndrome ◽  
Macrophage Activation ◽  
Orotracheal Intubation ◽  
Excellent Outcome ◽  
High Doses ◽  
Excellent Clinical Outcome ◽  
Activation Syndrome

Abstract In severe cases of COVID-19, it is important to note that some laboratory signs may alert to the presence of underlying macrophage activation syndrome (MAS), and we ratify that the classic signs of primary MAS are often not present. Here we show a case report of COVID-19 complicated by MAS treated with high doses of methylprednisolone and intravenous Immunoglobulin, with excellent clinical outcome, avoiding orotracheal intubation indeed. The interpretation of laboratory signs leads to early diagnosis and the introduction of effective therapy.

scholarly journals Thrombolysis Implementation Intervention and Clinical Outcome: A Secondary Analysis of a Cluster Randomized Trial.

2020 ◽  
Author(s):  
Md Golam Hasnain ◽  
Christine L Paul ◽  
John R Attia ◽  
Annika Ryan ◽  
Erin Kerr ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Odds Ratio ◽  
Intravenous Thrombolysis ◽  
Control Group ◽  
Intervention Period ◽  
Poor Clinical Outcome ◽  
Post Intervention ◽  
Lower Odds ◽  
Individual Level ◽  
Post Intervention Period

Abstract Background Multiple studies have attempted to increase the rate of intravenous thrombolysis for ischemic stroke using interventions to promote adherence to guidelines. Still, many of them did not measure individual-level impact. This study aimed to make a posthoc comparison of the clinical outcomes of patients in the “Thrombolysis ImPlementation in Stroke (TIPS)” study, which aimed to improve rates of intravenous thrombolysis in Australia.Methods A posthoc analysis was conducted using individual-level patient data. Excellent and poor clinical outcome and parenchymal haematoma were the three main outcomes, and a mixed logistic regression model was used to assess the difference between the intervention and control groups.Results There was a non-significantly higher odds of having an excellent clinical outcome of 57% (odds ratio: 1.57; 95% CI: 0.73–3.39) and 33% (odds ratio: 1.33; 95% CI: 0.73–2.44) during the active-and post-intervention period respectively, for the intervention compared to the control group. A non-significantly lower odds of having a poor clinical outcome was also found in the intervention, relative to control group of 4% (odds ratio: 0.96; 95% CI: 0.56–2.07) and higher odds of having poor outcome of 44% (odds ratio: 1.44 95% CI: 0.61–3.41) during both active and post-intervention period respectively. Similarly, a non-significant lower odds of parenchymal haematoma was also found for the intervention group during the both active- (odds ratio: 0.53; 95% CI: 0.21–1.32) and post-intervention period (odds ratio: 0.96; 95% CI: 0.36–2.52).Conclusion The TIPS multi-component implementation approach was not effective in reducing the odds of post-treatment severe disability at 90 days, or post-thrombolysis hemorrhage.Trial registration Clinical Trial Registration-URL: http://www.anzctr.org.au/ Unique Identifier: ACTRN12613000939796.

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