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1.
  • Ahmed, Niaz, et al. (författare)
  • The SITS Open Study: A Prospective, Open Label Blinded Evaluation Study of Thrombectomy in Clinical Practice.
  • 2021
  • Ingår i: Stroke. - 1524-4628. ; 52:3, s. 792-801
  • Tidskriftsartikel (refereegranskat)abstract
    • We designed SITS (Safe Implementation of Treatment in Stroke) Open to determine benefit and safety of thrombectomy in clinical practice for large artery occlusion stroke, using selected stent retrievers plus standard care versus standard care alone.SITS Open was a prospective, open, blinded evaluation, international, multicenter, controlled, nonrandomized registry study. Centers lacking access to thrombectomy contributed controls. Primary end point was categorical shift in modified Rankin Scale score at 3 months in the per protocol (PP) population. Principal secondary outcomes were symptomatic intracranial hemorrhage, functional independency (modified Rankin Scale score 0-2) and death at 3 months. Patients independently evaluated by video-recorded modified Rankin Scale interviews blinded to treatment or center identity by central core laboratory were regarded as PP population. Propensity score matching with covariate adjusted analysis was performed.During 2014 to 2017, 293 patients (257 thrombectomy, 36 control) from 26 centers in 10 countries fulfilled intention-to-treat and 200 (170 thrombectomy, 30 control) PP criteria; enrollment of controls was limited by rapid uptake of thrombectomy. In PP analysis, median age was 71 versus 71 years, and baseline National Institutes of Health Stroke Scale 17 versus 17 in the thrombectomy and control arms, respectively. The propensity score matching analysis for PP showed a significant shift for modified Rankin Scale at 3 months favoring the thrombectomy group (odds ratio, 3.8 [95% CI, 1.61-8.95]; P=0.002). Regarding safety, there were 4 cases of symptomatic intracranial hemorrhage in the thrombectomy group (2.4%) and none in the control group.In clinical practice, thrombectomy for patients with large artery occlusion stroke is superior to standard of care in our study. Registration: URL: https://www.clinicaltrials.gov. Unique Identifier: NCT02326428.
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3.
  • Brinjikji, Waleed, et al. (författare)
  • Endotheliitis and cytokine storm as a mechanism of clot formation in COVID-19 ischemic stroke patients: A histopathologic study of retrieved clots.
  • 2023
  • Ingår i: Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences. - 2385-2011.
  • Tidskriftsartikel (refereegranskat)abstract
    • Studies during the COVID-19 pandemic have demonstrated an association between COVID-19 virus infection and the development of acute ischemic stroke, particularly large vessel occlusion (LVO). Studying the characteristics and immunohistochemistry of retrieved stroke emboli during mechanical thrombectomy for LVO may offer insights into the pathogenesis of LVO in COVID-19 patients. We examined retrieved COVID-19 emboli from the STRIP, EXCELLENT, and RESTORE registries and compared their characteristics to a control group.We identified COVID-positive LVO patients from the STRIP, RESTORE, and EXCELLENT studies who underwent mechanical thrombectomy. These patients were matched to a control group controlling for stroke etiology based on Trial of Org 10172 in Acute Stroke Treatment criteria. All clots were stained with Martius Scarlet Blue (MSB) along with immunohistochemistry for interleukin-6 (IL-6), C-reactive protein (CRP), von Willebrand factor (vWF), CD66b, fibrinogen, and citrullinated Histone H3. Clot composition was compared between groups.Nineteen COVID-19-positive patients and 38 controls were included. COVID-19-positive patients had a significantly higher percentage of CRP and vWF. There was no difference in IL-6, fibrin, CD66b, or citrullinated Histone H3 between groups. Based on MSB staining, there was no statistically significant difference regarding the percentage of red blood cells, white blood cells, fibrin, and platelets.Our study found higher concentrations of CRP and vWF in retrieved clots of COVID-19-positive stroke patients compared to COVID-19-negative controls. These findings support the potential role of systemic inflammation as indicated by elevated CRP and endothelial injury as indicated by elevated vWF as precipitating factors in thrombus development in these patients.
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4.
  • Douglas, Andrew, et al. (författare)
  • Platelet-rich emboli are associated with von Willebrand factor levels and have poorer revascularization outcomes.
  • 2020
  • Ingår i: Journal of neurointerventional surgery. - : BMJ. - 1759-8486 .- 1759-8478. ; 12:6
  • Tidskriftsartikel (refereegranskat)abstract
    • Platelets and von Willebrand factor (vWF) are key factors in thrombosis and thus are likely key components of acute ischemic stroke (AIS) emboli. We aimed to characterize platelet and vWF levels in AIS emboli and to assess associations between their expression levels and clinical and procedural information.Histopathological and immunohistochemical analysis of emboli collected as part of the multi-institutional RESTORE registry was performed. The composition of the emboli was quantified using Orbit Image Analysis machine learning software. Correlations between clot components and clinical and procedural information were assessed using the χ2 test.Ninety-one emboli samples retrieved from 63 patients were analyzed in the study. The mean platelet (CD42b) content of the clots was 33.9% and the mean vWF content of the clots was 29.8%. There was a positive correlation between platelet and vWF levels (ρ=0.564, p<0.001*, n=91). There was an inverse correlation between both platelets and vWF levels and percentage of red blood cells (RBCs) in the emboli (CD42b vs RBC: ρ=-0.535, p<0.001*, n=91; vWF vs RBC: ρ=-0.366, p<0.001*, n=91). Eighty-one percent of patients in the low platelet group had a good revascularization outcome (Thrombolysis in Cerebral Infarction 2c/3) compared with 58% in the high platelet group (χ2=5.856, p=0.016).Platelet and vWF levels in AIS emboli correlate with each other and both have an inverse relationship with RBC composition. Patients with platelet-rich clots have poorer revascularization outcomes.
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5.
  • Eriksson, Hanna, et al. (författare)
  • Acute symptomatic seizures and epilepsy after mechanical thrombectomy
  • 2020
  • Ingår i: Epilepsy and Behavior. - : Elsevier BV. - 1525-5050 .- 1525-5069. ; 104
  • Tidskriftsartikel (refereegranskat)abstract
    • Purpose: The purpose of this study was to assess the incidence of acute symptomatic seizures and poststroke epilepsy (PSE) in a well-characterized cohort of patients treated with mechanical thrombectomy. In addition, we aimed to describe the dynamics of blood markers of brain injury in patients that developed PSE. Methods: Participants of the prospective AnStroke Trial of anesthesia method during mechanical thrombectomy were included and acute symptomatic seizures and PSE ascertained by medical records review. Blood markers neurofilament light (NFL), tau, glial fibrillary acidic protein (GFAP), S100 calcium-binding protein B (S100B), and neuron-specific enolase (NSE) were assessed. Results: A total of 90 patients with acute anterior ischemic stroke were included. Median National Institutes of Health Stroke Scale (NIHSS) at admission to hospital was 18 (IQR 15–22). Recanalization was achieved in 90%. No patients had epilepsy prior to the ischemic stroke. Four patients (4.4%) had acute symptomatic seizures and four patients (4.4%) developed PSE during the follow-up time (to death or last medical records review) of 0–4.5 years (median follow-up 1070 days IQR 777–1306), resulting in a two-year estimated PSE risk of 5.3% (95%CI: 0.2–10.4%). Blood markers of brain injury (NFL, tau, GFAP, S100B, and NSE) were generally above the cohort median in patients that developed PSE. Conclusions: The incidence of PSE after mechanical thrombectomy was low in our cohort. All blood biomarkers displayed interesting sensitivity and specificity. However, the number of PSE cases was small and more studies are needed on risk factors for PSE after mechanical thrombectomy. The potential of blood markers of brain injury markers to contribute to assessment of PSE risk should be explored further. This article is part of the Special Issue "Seizures & Stroke".
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6.
  • Eriksson, Hanna, et al. (författare)
  • Risk of poststroke epilepsy after reperfusion therapies: A national cohort study
  • 2023
  • Ingår i: European Journal of Neurology. - : Wiley. - 1351-5101 .- 1468-1331. ; 30:5, s. 1303-1311
  • Tidskriftsartikel (refereegranskat)abstract
    • Background and purpose: The risk of poststroke epilepsy (PSE) after endovascular treatment (EVT) is not well characterized. In this nationwide study, we assessed the risk of PSE after EVT and identified associated predictors.Methods: We included all individuals (n = 3319) treated with EVT (& PLUSMN;intravenous thrombolysis [IVT]) between 2015 and 2019 in the Swedish National Quality Register for EVT. Two control groups were identified from the Swedish Stroke Register: the first treated with IVT alone (n = 3132) and the second with no treatment (n = 3184), both matched for age, sex, stroke severity, and time of stroke.Results: PSE developed in 7.9% (n = 410). The survival-adjusted 2-year risk was 6.5% (95% confidence interval [CI] = 5.28-7.70) after EVT, 10.0% (95% CI = 8.25-11.75) after IVT, and 12.3% after no revascularization (95% CI = 10.33-14.25). The hazard ratio (HR) of PSE after EVT was almost half compared to no treatment (HR = 0.51, 95% CI = 0.41-0.64). The risk of PSE after EVT was lower compared to no treatment in a multivariable Cox model that adjusted for age, sex, hemicraniectomy, and stroke severity (HR = 0.76, 95% CI = 0.60-0.96). Multivariable predictors of PSE after EVT were large infarction on computed tomography Day 1, high posttreatment National Institutes of Health Stroke Scale score, and need of assistance 3 months after stroke. IVT before EVT was associated with a lower risk of PSE (HR = 0.66, 95% CI = 0.46-0.94).Conclusions: This nationwide study identified a reduced risk of PSE after EVT. Markers of severe infarction after EVT were associated with PSE, whereas IVT given before EVT was protective.
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7.
  • Filioglo, A, et al. (författare)
  • Outcomes after reperfusion therapies in patients with ACA stroke: A multicenter cohort study from the EVATRISP collaboration.
  • 2022
  • Ingår i: Journal of the neurological sciences. - : Elsevier BV. - 1878-5883 .- 0022-510X. ; 432
  • Tidskriftsartikel (refereegranskat)abstract
    • Patients with stroke secondary to occlusions of the anterior cerebral artery (ACA) often have poor outcomes. The optimal acute therapeutic intervention for these patients remains unknown.Patients with isolated ACA-stroke were identified from 10 centers participating in the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) prospective registry. Patients treated with endovascular thrombectomy (EVT) were compared to those treated with intravenous thrombolysis (IVT). Odds ratios with 95% confidence intervals (OR; 95%CI) were calculated using multivariate regression analysis.Included were 92 patients with ACA-stroke. Of the 92 ACA patients, 55 (60%) were treated with IVT only and 37 (40%) with EVT (±bridging IVT). ACA patients treated with EVT had more often wake-up stroke (24% vs. 6%, p=0.044) and proximal ACA occlusions (43% vs. 24%, p=0.047) and tended to have higher stroke severity on admission [NIHSS: 10.0 vs 7.0, p=0.054). However, odds for favorable outcome, mortality or symptomatic intracranial hemorrhage did not differ significantly between both groups. Exploration of the effect of clot location inside the ACA showed that in patients with A1 or A2/A3 ACA occlusions the chances of favorable outcome were not influenced by treatment allocation to IVT or EVT.Treatment with either IVT or EVT could be safe with similar effect in patients with ACA-strokes and these effects may be independent of clot location within the occluded ACA.
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8.
  • Fitzgerald, Seán, et al. (författare)
  • Large Artery Atherosclerotic Clots are Larger than Clots of other Stroke Etiologies and have Poorer Recanalization rates.
  • 2021
  • Ingår i: Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. - : Elsevier BV. - 1532-8511. ; 30:1
  • Tidskriftsartikel (refereegranskat)abstract
    • There is a paucity of knowledge in the literature relating to the extent of clot burden and stroke etiology. In this study, we measured the Extracted Clot Area (ECA) retrieved during endovascular treatment (EVT) and investigated relationships with suspected etiology, administration of intravenous thrombolysis and recanalization.As part of the multi-institutional RESTORE registry, the ECA retrieved during mechanical thrombectomy was quantified using ImageJ. The effect of stroke etiology (Large-artery atherosclerosis (LAA), Cardioembolism, Cryptogenic and other) and recombinant tissue plasminogen activator (rtPA) on ECA and recanalization outcome (mTICI) was assessed. Successful recanalization was described as mTICI 2c-3.A total of 550 patients who underwent EVT with any clot retrieved were included in the study. The ECA was significantly larger in the LAA group compared to all other etiologies. The average ECA size of each etiology was; LAA=109mm2, Cardioembolic=52mm2, Cryptogenic=47mm2 and Other=52mm2 (p=0.014*). LAA patients also had a significantly poorer rate of successful recanalization (mTICI 2c-3) compared to all other etiologies (p=0.003*). The administration of tPA was associated with a smaller ECA in both LAA (p=0.007*) and cardioembolic (p=0.035*) groups.The ECA of LAA clots was double the size of all other etiologies and this is associated with a lower rate of successful recanalization in LAA stroke subtype. rtPA administration prior to thrombectomy was associated with reduced ECA in LAA and CE clots.
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9.
  • Fitzgerald, Seán, et al. (författare)
  • Per-pass analysis of acute ischemic stroke clots: impact of stroke etiology on extracted clot area and histological composition.
  • 2021
  • Ingår i: Journal of neurointerventional surgery. - : BMJ. - 1759-8486 .- 1759-8478. ; 13, s. 1111-1116
  • Tidskriftsartikel (refereegranskat)abstract
    • Initial studies investigating correlations between stroke etiology and clot composition are conflicting and do not account for clot size as determined by area. Radiological studies have shown that cardioembolic strokes are associated with shorter clot lengths and lower clot burden than non-cardioembolic clots.To report the relationship between stroke etiology, extracted clot area, and histological composition at each procedural pass.As part of the multi-institutional RESTORE Registry, the Martius Scarlett Blue stained histological composition and extracted clot area of 612 per-pass clots retrieved from 441 patients during mechanical thrombectomy procedures were quantified. Correlations with clinical and procedural details were investigated.Clot composition varied significantly with procedural passes; clots retrieved in earlier passes had higher red blood cell content (H4=11.644, p=0.020) and larger extracted clot area (H4=10.730, p=0.030). Later passes were associated with significantly higher fibrin (H4=12.935, p=0.012) and platelets/other (H4=15.977, p=0.003) content and smaller extracted clot area. Large artery atherosclerotic (LAA) clots were significantly larger in the extracted clot area and more red blood cell-rich than other etiologies in passes 1-3. Cardioembolic and cryptogenic clots had similar histological composition and extracted clot area across all procedural passes.LAA clots are larger and associated with a large red blood cell-rich extracted clot area, suggesting soft thrombus material. Cardioembolic clots are smaller in the extracted clot area, consistent in composition and area across passes, and have higher fibrin and platelets/other content than LAA clots, making them stiffer clots. The per-pass histological composition and extracted clot area of cryptogenic clots are similar to those of cardioembolic clots, suggesting similar formation mechanisms.
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10.
  • Goyal, Nitin, et al. (författare)
  • Medical Management vs Mechanical Thrombectomy for Mild Strokes: An International Multicenter Study and Systematic Review and Meta-analysis
  • 2020
  • Ingår i: JAMA Neurology. - : American Medical Association (AMA). - 2168-6149. ; 77:1, s. 16-24
  • Tidskriftsartikel (refereegranskat)abstract
    • © 2019 American Medical Association. All rights reserved. Importance: The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score <6) owing to emergency large-vessel occlusion (ELVO) remains uncertain. Objective: To assess the outcomes of patients with mild-deficits ELVO (mELVO) treated with MT vs best medical management (bMM). Data Sources: We retrospectively pooled patients with mELVO during a 5-year period from 16 centers. A meta-analysis of studies reporting efficacy and safety outcomes with MT or bMM among patients with mELVO was also conducted. Data were analyzed between 2013 and 2017. Study Selection: We identified studies that enrolled patients with stroke (within 24 hours of symptom onset) with mELVO treated with MT or bMM. Main Outcomes and Measures: Efficacy outcomes included 3-month favorable functional outcome and 3-month functional independence that were defined as modified Rankin Scale scores of 0 to 1 and 0 to 2, respectively. Safety outcomes included 3-month mortality and symptomatic and asymptomatic intracranial hemorrhage (ICH). Results: We evaluated a total of 251 patients with mELVO who were treated with MT (n = 138; 65 women; mean age, 65.2 years; median NIHSS score, 4; interquartile range [IQR], 3-5) or bMM (n = 113; 51 women; mean age, 64.8; median NIHSS score, 3; interquartile range [IQR], 2-4). The rate of asymptomatic ICH was lower in bMM (4.6% vs 17.5%; P =.002), while the rate of 3-month FI (after imputation of missing follow-up evaluations) was lower in MT (77.4% vs 88.5%; P =.02). The 2 groups did not differ in any other efficacy or safety outcomes. In multivariable analyses, MT was associated with higher odds of asymptomatic ICH (odds ratio [OR], 11.07; 95% CI, 1.31-93.53; P =.03). In the meta-analysis of 4 studies (843 patients), MT was associated with higher odds of symptomatic ICH in unadjusted analyses (OR, 5.52; 95% CI, 1.91-15.49; P =.002; I2 = 0%). This association did not retain its significance in adjusted analyses including 2 studies (OR, 2.06; 95% CI, 0.49-8.63; P =.32; I2 = 0%). The meta-analysis did not document any other independent associations between treatment groups and safety or efficacy outcomes. Conclusions and Relevance: Our multicenter study coupled with the meta-analysis suggests similar outcomes of MT and bMM in patients with stroke with mELVO, but no conclusions about treatment effect can be made. The clinical equipoise can further be resolved by a randomized clinical trial.
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11.
  • Jabrah, Duaa, et al. (författare)
  • White blood cell subtypes and neutrophil extracellular traps content as biomarkers for stroke etiology in acute ischemic stroke clots retrieved by mechanical thrombectomy.
  • 2024
  • Ingår i: Thrombosis research. - 1879-2472. ; 234, s. 1-8
  • Tidskriftsartikel (refereegranskat)abstract
    • Lymphocytes, macrophages, neutrophils, and neutrophil extracellular traps (NETs) associate with stroke risk factors and form a thrombus through different mechanisms. We investigated the total WBCs, WBC subtypes and NETs composition in acute ischemic stroke (AIS) clots to identify possible etiological differences that could help us further understand the process of thrombosis that leads to AIS.AIS clots from 100 cases each of atherothrombotic (AT), cardioembolic (CE) and cryptogenic stroke etiology were collected per-pass as part of the CÚRAM RESTORE registry of AIS clots. Martius Scarlet Blue stain was used to identify the main histological components of the clots. Immunohistochemical staining was used to identify neutrophils, lymphocytes, macrophages, and NETs patterns. The cellular and histological components were quantified using Orbit Image Analysis software.AT clots were larger, with more red blood cells and fewer WBCs than CE clots. AT clots had more lymphocytes and cryptogenic clots had fewer macrophages than other etiologies. Most significantly, CE clots showed higher expression of neutrophils and extracellular web-like NETs compared to AT and cryptogenic clots. There was also a significantly higher distribution of web-like NETs around the periphery of the CE clots while a mixed distribution was observed in AT clots.The difference in neutrophil and NETs expression in clots from different etiologies may provide insight into the mechanism of clot formation.
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12.
  • Karlsson, Adrian, et al. (författare)
  • Extended treatment in cerebral ischemia score 2c or 3 as goal of successful endovascular treatment is associated with clinical benefit.
  • 2024
  • Ingår i: Journal of neuroradiology = Journal de neuroradiologie. - 0150-9861. ; 51:2, s. 190-195
  • Tidskriftsartikel (refereegranskat)abstract
    • Successful reperfusion, defined as a modified treatment in cerebral ischemia (mTICI) score 2b or 3, is an important goal for endovascular treatment (EVT) of stroke. Recently, an extension of the mTICI score with an additional grade 2c indicating near-complete reperfusion (expanded TICI, eTICI) and a revised definition of success as eTICI 2c or 3 were proposed. We evaluate whether eTICI 2c translates into improved clinical outcome compared to eTICI 2b.Consecutive patients with large vessel occlusion in the anterior circulation who underwent EVT between December 2013 and December 2020 were included. Clinical outcome measures were favorable functional outcome at 90 days (modified Rankin Scale [mRS] scores 0 to 2 or return to pre-stroke mRS) and early neurological improvement (National Institutes of Health Stroke Scale [NIHSS] improvement ≥4 points or a score of 0-1 at 24h).Of 1282 included patients (median age 76, median NIHSS 16), reperfusion was classified as eTICI 2b in 410 (32%), eTICI 2c in 242 (19%) and eTICI 3 in 464 (36%). eTICI 2c differed significally from 2b with respect to early neurological improvement (aOR=1.49, 95% CI=1.01-2.19). No statistically significant difference in favorable functional outcome at 90 days was found (eTICI 2c vs 2b, aOR=1.31, 95% CI=0.88-2.00).Our study indicates early clinical benefit at 24h of achieving eTICI 2c compared to eTICI 2b, but no significant difference was seen in favorable functional outcome at 90 days. Our results support eTICI 2c and 3 as the goal of a successful thrombectomy but do not exclude eTICI 2b as an acceptable result.
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13.
  • Karlsson, Adrian, et al. (författare)
  • Stent retriever versus aspiration based thrombectomy: impact on first pass reperfusion, procedure time, and clinical outcomes in large vessel occlusion. Nationwide registry based cohort study
  • 2024
  • Ingår i: JOURNAL OF NEUROINTERVENTIONAL SURGERY. - 1759-8478 .- 1759-8486.
  • Tidskriftsartikel (refereegranskat)abstract
    • Background First pass reperfusion (FPR), defined as near complete reperfusion (extended Treatment in Cerebral Ischemia (eTICI) score 2c/3) in a single attempt without rescue therapy has been proposed as a quality metric. However, it remains unclear if the thrombectomy method influences clinical outcome and FPR rate. This study evaluates whether stent retriever and aspiration based thrombectomy differ in FPR rate, technical and clinical outcomes in FPR, and multiple pass reperfusion (MPR).Methods This retrospective, nationwide, multicenter registry study included consecutive patients with proximal anterior or posterior circulation stroke, treated between 2018 and 2021 in Sweden. Outcome measures were FPR rate, procedure time, early neurological improvement (>= 4 points on National Institutes of Health Stroke Scale (NIHSS) or a score of 0-1 at 24 hours), favorable functional outcome (modified Rankin Scale score of 0-2 or no decline at 90 days), and mortality at 90 days.Results Of 3309 patients (median age 75, median NIHSS 16), 1990 underwent stent retriever and 1319 aspiration based thrombectomy as the firstline method. No difference in FPR rate was observed. Aspiration based thrombectomy showed a shorter procedure time in the FPR group (crude OR (cOR) 6.4 min (95% CI 3.4 to 9.3), adjusted OR (aOR) 8.7 min (95% CI 1.8 to 15.6)) and MPR group (cOR 9.7 min (95% CI 4.0 to 15.4), aOR 17.4 min (95% CI 9.6 to 25.2)), and association with early neurological improvement (cOR 1.21 (95% CI 1.03 to 1.42), aOR 1.40 (95% CI 1.18 to 1.67)) and favorable functional outcome (aOR 1.22 (95% CI 1.01 to 1.47)).Conclusions Our findings suggest that aspiration based thrombectomy was associated with a shorter procedure time and better clinical outcomes than treatment with a stent retriever. No difference was found in FPR rate.
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14.
  • Katsanos, Aristeidis H, et al. (författare)
  • Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis.
  • 2022
  • Ingår i: Neurology. - 1526-632X. ; 98:3
  • Tidskriftsartikel (refereegranskat)abstract
    • To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model.A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT.Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.
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15.
  • Larsson, Alice, et al. (författare)
  • Do patients with large vessel occlusion ischemic stroke harboring prestroke disability benefit from thrombectomy?
  • 2020
  • Ingår i: Journal of Neurology. - : Springer Science and Business Media LLC. - 0340-5354 .- 1432-1459. ; 267, s. 2667-2674
  • Tidskriftsartikel (refereegranskat)abstract
    • Objectives: Evidence of endovascular treatment (EVT) for acute large vessel occlusion (LVO) ischemic stroke in patients harboring substantial prestroke disability is lacking due to their exclusion from randomized trials. Here, we used routine care observational data to compare outcomes in patients with and without prestroke disability receiving EVT for LVO ischemic stroke. Methods: Consecutive patients undergoing EVT for acute LVO ischemic stroke at the Sahlgrenska University Hospital from January 1st, 2015 to March 31st, 2018 were registered in the Sahlgrenska Stroke Recanalization Registry. Pre- and poststroke functional levels were assessed by the modified Rankin Scale (mRS). Outcomes were recanalization rate (mTICI = 2b/3), symptomatic intracranial hemorrhage [sICH], complications during hospital stay, and return to prestroke functional level and mortality at 3 months. Results: Among 591 patients, 90 had prestroke disability (mRS ≥ 3). The latter group were older, more often female, had more comorbidities and higher NIHSS scores before intervention compared to patients without prestroke disability. Recanalization rates (80.0% vs 85.0%, p = 0.211), sICH (2.2% vs 6.3% p = 0.086) and the proportion of patients returning to prestroke functional level (22.7% vs 14.8% p = 0.062) did not significantly differ between those with and without prestroke disability. Patients with prestroke disability had higher complication rates during hospital stay (55.2% vs 40.1% p < 0.01) and mortality at 3 months (48.9% vs 24.3% p < 0.001). Conclusion: One of five with prestroke disability treated with thrombectomy for a LVO ischemic stroke returned to their prestroke functional level. However, compared to patients without prestroke disability, mortality at 3 months was higher. © 2020, The Author(s).
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16.
  • Lindgren, Erik, 1993, et al. (författare)
  • Dural arteriovenous fistulas in cerebral venous thrombosis Data from the International Cerebral Venous Thrombosis Consortium
  • 2022
  • Ingår i: European Journal of Neurology. - : Wiley. - 1351-5101 .- 1468-1331. ; 29:3, s. 761-770
  • Tidskriftsartikel (refereegranskat)abstract
    • Background and purpose To explore the prevalence, risk factors, time correlation, characteristics and clinical outcome of dural arteriovenous fistulas (dAVFs) in a cerebral venous thrombosis (CVT) population. Methods We included patients from the International CVT Consortium registries. Diagnosis of dAVF was confirmed centrally. We assessed the prevalence and risk factors for dAVF among consecutive CVT patients and investigated its impact on clinical outcome using logistic regression analysis. We defined poor outcome as modified Rankin Scale score 3-6 at last follow-up. Results dAVF was confirmed in 29/1218 (2.4%) consecutive CVT patients. The median (interquartile range [IQR]) follow-up time was 8 (5-23) months. Patients with dAVF were older (median [IQR] 53 [44-61] vs. 41 [29-53] years; p < 0.001), more frequently male (69% vs. 33%; p < 0.001), more often had chronic clinical CVT onset (>30 days: 39% vs. 7%; p < 0.001) and sigmoid sinus thrombosis (86% vs. 51%; p < 0.001), and less frequently had parenchymal lesions (31% vs. 55%; p = 0.013) at baseline imaging. Clinical outcome at last follow-up did not differ between patients with and without dAVF. Additionally, five patients were confirmed with dAVF from non-consecutive CVT cohorts. Among all patients with CVT and dAVF, 17/34 (50%) had multiple fistulas and 23/34 (68%) had cortical venous drainage. Of 34 patients with dAVF with 36 separate CVT events, 3/36 fistulas (8%) were diagnosed prior to, 20/36 (56%) simultaneously and 13/36 after (36%, median 115 [IQR 38-337] days) diagnosis of CVT. Conclusions Dural arteriovenous fistulas occur in at least 2% of CVT patients and are associated with chronic CVT onset, older age and male sex. Most CVT-related dAVFs are detected simultaneously or subsequently to diagnosis of CVT.
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17.
  • Löwhagen Hendén, Pia, et al. (författare)
  • General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke: The AnStroke Trial (Anesthesia During Stroke).
  • 2017
  • Ingår i: Stroke. - 1524-4628. ; 48:6, s. 1601-1607
  • Tidskriftsartikel (refereegranskat)abstract
    • Retrospective studies have found that patients receiving general anesthesia for endovascular treatment in acute ischemic stroke have worse neurological outcome compared with patients receiving conscious sedation. In this prospective randomized single-center study, we investigated the impact of anesthesia technique on neurological outcome in acute ischemic stroke patients.Ninety patients receiving endovascular treatment for acute ischemic stroke in 2013 to 2016 were included and randomized to general anesthesia or conscious sedation. Difference in neurological outcome at 3 months, measured as modified Rankin Scale score, was analyzed (primary outcome) and early neurological improvement of National Institutes of Health Stroke Scale and cerebral infarction volume. Age, sex, comorbidities, admission National Institutes of Health Stroke Scale score, intraprocedural blood pressure, blood glucose, Paco2 and Pco2 modified Thrombolysis in Cerebral Ischemia score, and relevant time intervals were recorded.In the general anesthesia group 19 of 45 patients (42.2%) and in the conscious sedation group 18 of 45 patients (40.0%) achieved a modified Rankin Scale score ≤2 (P=1.00) at 3 months, with no differences in intraoperative blood pressure decline from baseline (P=0.57); blood glucose (P=0.94); PaCO2 (P=0.68); time intervals (P=0.78); degree of successful recanalization, 91.1% versus 88.9% (P=1.00); National Institutes of Health Stroke Scale score at 24 hours 8 (3-5) versus 9 (2-15; P=0.60); infarction volume, 20 (10-100) versus 20(10-54) mL (P=0.53); and hospital mortality (13.3% in both groups; P=1.00).In endovascular treatment for acute ischemic stroke, no difference was found between general anesthesia and conscious sedation in neurological outcome 3 months after stroke.URL: https://www.clinicaltrials.gov. Unique identifier: NCT01872884.
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18.
  • Löwhagen Hendén, Pia, et al. (författare)
  • Hypotension During Endovascular Treatment of Ischemic Stroke Is a Risk Factor for Poor Neurological Outcome.
  • 2015
  • Ingår i: Stroke; a journal of cerebral circulation. - 1524-4628. ; 46:9, s. 2678-2680
  • Tidskriftsartikel (refereegranskat)abstract
    • In retrospective studies, patients receiving general anesthesia for endovascular treatment for acute ischemic stroke have worse neurological outcome compared with patients receiving conscious sedation. It has been suggested that this is caused by general anesthesia-associated hypotension. We investigated the effect of intraprocedural hypotension on neurological outcome.
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19.
  • Löwhagen Hendén, Pia, et al. (författare)
  • Off-hour admission and impact on neurological outcome in endovascular treatment for acute ischemic stroke
  • 2019
  • Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley. - 0001-5172 .- 1399-6576. ; 36:2, s. 208-214
  • Tidskriftsartikel (refereegranskat)abstract
    • © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Background and Purpose: In the new era of endovascular treatment for acute ischemic stroke, one of the main predictors of good neurological outcome is a short time interval from stroke onset to recanalization of the occluded vessel. In this study, we examined the effect of on-hour vs off-hour admittance on the time intervals from stroke onset to recanalization in patients with acute ischemic stroke (AIS) undergoing endovascular treatment (EVT). Methods: One-hundred-ninety-eight patients receiving EVT for anterior AIS between 2007 and 2016 were included. Time of day and weekday for stroke admittance were recorded as well as several time intervals. Age, sex, co-morbidities, admission National Institutes of Health Stroke Scale (NIHSS), intraprocedural blood pressure, blood glucose, modified Thrombolysis in Cerebral Ischemia score (mTICI) and neurological outcome at 3months, measured as modified Rankin Scale (mRS), were registered. On-hour was defined as 8am-4pm weekdays, and off-hour as weekdays outside these hours and weekends. Results: The time interval from CT (computed tomography) to recanalization was longer during off-hours, while no difference was seen in the time interval from stroke onset to CT. No statistically significant difference was seen in neurological outcome between the on- and off-hour groups in a univariate analysis. Conclusions: Stroke admittance during off-hours is associated with longer time interval from CT examination to vessel recanalization. The study highlights the need of logistic improvement and probably more resources off-hour in order to deliver an effective stroke care around the clock.
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20.
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21.
  • Mereuta, O. M., et al. (författare)
  • Characterization of the 'White' Appearing Clots that Cause Acute Ischemic Stroke
  • 2021
  • Ingår i: Journal of Stroke and Cerebrovascular Diseases. - : Elsevier BV. - 1052-3057. ; 30:12
  • Tidskriftsartikel (refereegranskat)abstract
    • Objectives: Most clots retrieved from patients with acute ischemic stroke are 'red' in color. 'White' clots represent a less common entity and their histological composition is less known. Our aim was to investigate the composition, imaging and procedural characteristics of 'white' clots retrieved by mechanical thrombectomy. Materials and methods: Seventy five 'white' thrombi were selected by visual inspection from a cohort of 760 clots collected as part of the RESTORE registry. Clots were evaluated histopathologically. Results: Quantification of Martius Scarlett Blue stain identified platelets/other as the major component in 'white' clots' (mean of 55% of clot overall composition) followed by fibrin (31%), red blood cells (6%) and white blood cells (3%). 'White' clots contained significantly more platelets/other (p<0.001*) and collagen/calcification (p<0.001*) and less red blood cells (p<0.001*) and white blood cells (p=0.018*) than 'red' clots. The mean platelet and von Willebrand Factor expression was 43% and 24%, respectively. Adipocytes were found in four cases. 'White' clots were significantly smaller (p=0.016*), less hyperdense (p=0.005*) on computed tomography angiography/non-contrast CT and were associated with a smaller extracted clot area (p<0.001*) than 'red' clots. They primarily caused the occlusion of middle cerebral artery, were less likely to be removed by aspiration and more likely to require rescue-therapy for retrieval. Conclusions: 'White' clots represented 14% of our cohort and were platelet, von Willebrand Factor and collagen/calcification-rich. 'White' clots were smaller, less hyperdense, were associated with significantly more distal occlusions and were less successfully removed by aspiration alone than 'red' clots.
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22.
  • Nordanstig, Annika, 1974, et al. (författare)
  • EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry.
  • 2021
  • Ingår i: BMJ open. - : BMJ. - 2044-6055. ; 11:8
  • Tidskriftsartikel (refereegranskat)abstract
    • The Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration was a concerted effort initiated in 2010 with the purpose to address relevant research questions about the effectiveness and safety of intravenous thrombolysis (IVT). The collaboration also aims to prospectively collect data on patients undergoing endovascular treatment (EVT) and hence the name of the collaboration was changed from TRISP to EVA-TRISP. The methodology of the former TRISP registry for patients treated with IVT has already been published. This paper focuses on describing the EVT part of the registry.All centres committed to collecting predefined variables on consecutive patients prospectively. We aim for accuracy and completeness of the data and to adapt local databases to investigate novel research questions. Herein, we introduce the methodology of a recently constructed academic investigator-initiated open collaboration EVT registry built as an extension of an existing IVT registry in patients with acute ischaemic stroke (AIS).Currently, the EVA-TRISP network includes 20 stroke centres with considerable expertise in EVT and maintenance of high-quality hospital-based registries. Following several successful randomised controlled trials (RCTs), many important clinical questions remain unanswered in the (EVT) field and some of them will unlikely be investigated in future RCTs. Prospective registries with high-quality data on EVT-treated patients may help answering some of these unanswered issues, especially on safety and efficacy of EVT in specific patient subgroups.This collaborative effort aims at addressing clinically important questions on safety and efficacy of EVT in conditions not covered by RCTs. The TRISP registry generated substantial novel data supporting stroke physicians in their daily decision making considering IVT candidate patients. While providing observational data on EVT in daily clinical practice, our future findings may likewise be hypothesis generating for future research as well as for quality improvement (on EVT). The collaboration welcomes participation of further centres willing to fulfill the commitment and the outlined requirements.
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23.
  • Pujol-Calderón, Fani, et al. (författare)
  • Prediction of Outcome After Endovascular Embolectomy in Anterior Circulation Stroke Using Biomarkers.
  • 2022
  • Ingår i: Translational stroke research. - : Springer Science and Business Media LLC. - 1868-601X .- 1868-4483. ; 13, s. 65-76
  • Tidskriftsartikel (refereegranskat)abstract
    • Stroke is a major public health problem that can cause a long-term disability or death due to brain damage. Serious stroke is frequently caused by a large vessel occlusion in the anterior circulation, which should be treated by endovascular embolectomy if possible. In this study, we investigated the use of the brain damage biomarkers tau, NFL, NSE, GFAp, and S100B to understand the progression of nervous tissue damage and their relationship to outcome in such stroke after endovascular treatment. Blood samples were taken from 90 patients pre-treatment and 2 h, 24 h, 48 h, 72 h and 3 months after endovascular treatment. Stroke-related neurological deficit was estimated using the National Institute of Health Stroke Scale (NIHSS) at admission and at 24 h. Neurological outcome was evaluated at 3 months. After stroke, tau, NFL, GFAp and S100B increased in a time dependent manner, while NSE remained constant over time. At 3 months, tau and GFAp levels were back to normal whereas NFL was still high. Tau, NFL and GFAp correlated well to outcome, as well as to infarct volume and NIHSS at 24 h. The best time for prediction of poor outcome was different for each biomarker. However, the combination of NIHSS at 24 h with either tau, NFL or GFAp at 48 h gave the best prediction. The use of biomarkers in the early setting after endovascular treatment of stroke will lead to a simplified and standardized way to estimate the nervous tissue damage and possibly complement the clinical judgement in foreseeing the need of rehabilitation measures.
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24.
  • Rasmussen, Mads, et al. (författare)
  • Blood Pressure Thresholds and Neurologic Outcomes After Endovascular Therapy for Acute Ischemic Stroke: An Analysis of Individual Patient Data From 3 Randomized Clinical Trials.
  • 2020
  • Ingår i: JAMA neurology. - : American Medical Association (AMA). - 2168-6157 .- 2168-6149. ; 77:5, s. 622-31
  • Tidskriftsartikel (refereegranskat)abstract
    • The optimal blood pressure targets during endovascular therapy (EVT) for acute ischemic stroke (AIS) are unknown.To study whether procedural blood pressure parameters, including specific blood pressure thresholds, are associated with neurologic outcomes after EVT.This retrospective cohort study included adults with anterior-circulation AIS who were enrolled in randomized clinical trials assessing anesthetic strategy for EVT between February 2014 and February 2017. The trials had comparable blood pressure protocols, and patients were followed up for 90 days. A total of 3630 patients were initially approached, and 3265 patients were excluded.Endovascular therapy.The primary efficacy variable was functional outcome as defined by the modified Rankin Scale (mRS) score at 90 days. Associations of blood pressure parameters and time less than and greater than mean arterial blood pressure (MABP) thresholds with outcome were analyzed.Of the 365 patients included in the analysis, the mean (SD) age was 71.4 (13.0) years, 163 were women (44.6%), and the median National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 14-21). For the entire cohort, 182 (49.9%) received general anesthesia and 183 (50.1%) received procedural sedation. A cumulated period of minimum 10 minutes with less than 70 mm Hg MABP (adjusted OR, 1.51; 95% CI, 1.02-2.22) and a continuous episode of minimum 20 minutes with less than 70 mm Hg MABP (adjusted OR, 2.30; 95% CI, 1.11-4.75) were associated with a shift toward higher 90-day mRS scores, corresponding to a number needed to harm of 10 and 4, respectively. A cumulated period of minimum 45 minutes with greater than 90 mm Hg MABP (adjusted OR, 1.49; 95% CI, 1.11-2.02) and a continuous episode of minimum 115 minutes with greater than 90 mm Hg MABP (adjusted OR, 1.89; 95% CI, 1.01-3.54) were associated with a shift toward higher 90-day mRS scores, corresponding to a number needed to harm of 10 and 6, respectively.Critical MABP thresholds and durations for poor outcome were found to be MABP less than 70 mm Hg for more than 10 minutes and MABP greater than 90 mm Hg for more than 45 minutes, both durations with a number needed to harm of 10 patients. Mean arterial blood pressure may be a modifiable therapeutic target to prevent or reduce poor functional outcome after EVT.
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25.
  • Rentzos, Alexandros, 1979 (författare)
  • Endovascular treatment of acute ischemic stroke
  • 2017
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • Background: Intravenous thrombolysis is effective in patients with minor stroke but not in patients with moderate or major stroke due to large vessel occlusion. Endovascular stroke treatment offers a high recanalization rate, which is associated with favorable neurological outcome. The aim of our studies was to evaluate the efficacy and safety of the endovascular stroke treatment in the anterior and posterior circulation, respectively, as performed in the Neurointerventional unit of Sahlgrenska University Hospital. Two major anesthesia forms are used in endovascular stroke treatment, general anesthesia, and conscious sedation. The aim was also to evaluate the impact of intra-procedural hypotension and to compare general anesthesia and conscious sedation with respect to radiological and neurological outcome. Methods: Paper I and Paper II are retrospective studies on efficacy and safety of endovascular stroke treatment in the anterior and posterior circulation, respectively. Paper III is a retrospective study on the impact of intraprocedural hypotension on neurological outcome in patients treated under general anesthesia. Paper IV is a prospective randomized study, where patients eligible for endovascular stroke treatment were randomized to general anesthesia or conscious sedation. Results: Paper I showed that the successful recanalization rate in endovascular stroke treatment in the anterior circulation was 74%, the complication rate was 5% and favorable neurological outcome at 3 months was found in 42%. Paper II showed successful recanalization in 73% of patients treated for stroke in the posterior circulation with serious procedural complications in 5 % and favorable outcome in 35% at 3 months. Paper III showed that a fall in mean arterial pressure of >40% is an independent predictor of poor neurological outcome. Paper IV showed no difference in neurological outcome at 3 months between patients randomized to general anesthesia or conscious sedation when a strict protocol for avoidance of intra-procedural hypotension was followed. Conclusion: Endovascular treatment in patients with acute ischemic stroke in the anterior and posterior circulation can achieve high recanalization rates with low complication rates. Intra-procedural hypotension is associated with poor neurological outcome but the choice of anesthesia method does not influence the neurological outcome if severe hypotension is avoided.
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26.
  • Rentzos, Alexandros, 1979, et al. (författare)
  • Endovascular treatment of acute ischemic stroke in the posterior circulation.
  • 2018
  • Ingår i: Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences. - : SAGE Publications. - 2385-2011. ; 24:4
  • Tidskriftsartikel (refereegranskat)abstract
    • Background and purpose Recent randomized clinical trials have proved the efficacy of endovascular treatment of acute ischemic stroke in the anterior circulation. However, the benefit of endovascular treatment of ischemic stroke in the posterior circulation remains to be proven since it was excluded from these trials. We evaluate the benefit of endovascular treatment in posterior circulation strokes. Methods A total of 110 consecutive patients with posterior circulation stroke who underwent endovascular treatment in our institute in the period 1991-2015 were included. Recanalization rate according to modified Treatment in Cerebral Ischemia score and neurological outcome at three months according to modified Rankin Scale were the main outcomes. Collateral circulation, procedural complications and radiological outcome were evaluated in the radiological examinations. Results The median National Institutes of Health Stroke Scale was 31 (IQR: 13-31) and median time from symptom onset to groin puncture was 300 (IQR: 175-463) minutes. Successful recanalization was seen in 80 of 110 patients (73%). Favorable outcome (modified Rankin Scale ≤2) was seen in 38 patients (35%) while moderate favorable outcome (≤3) was seen in 48 patients (44%). Symptomatic intracerebral hemorrhage occurred in 10 patients (9%). An association between collateral circulation, recanalization rate and outcome was seen. Conclusion Endovascular treatment for posterior circulation stroke in this single-center cohort is relatively safe and effective with decreased mortality and increased favorable outcome compared to natural history.
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27.
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28.
  • Rosengren, Lars, 1954, et al. (författare)
  • Värna utförarens kompetens vid intrakraniell trombektomi
  • 2018
  • Ingår i: Läkartidningen. - 0023-7205. ; 2018:115
  • Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
    • Den snabbkurs för kardiologer om 3–6 månader som föreslås av Sjögren och medförfattare utgör endast en bråkdel av den utbildningsinsats som det finns konsensus om, skriver 12 medlemmar i Nationella arbetsgruppen för stroke i en replik om trombektomi. De föreslår att ett modernt nationellt ambulanshelikoptersystem etableras.
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29.
  • Rossi, R., et al. (författare)
  • Correlation between acute ischaemic stroke clot length before mechanical thrombectomy and extracted clot area: Impact of thrombus size on number of passes for clot removal and final recanalization
  • 2021
  • Ingår i: European Stroke Journal. - : SAGE Publications. - 2396-9873 .- 2396-9881. ; 6:3, s. 254-261
  • Tidskriftsartikel (refereegranskat)abstract
    • Introduction: We assessed the correlation between thrombus size before and after mechanical thrombectomy, measured as length by Computed Tomography Angiography/Non-Contrast Computed Tomography (CTA/NCCT) and Extracted Clot Area, ECA, respectively. We also assessed the influence of thrombus size on the number of passes required for clot removal and final recanalization outcome. Materials and methods: Acute ischaemic stroke (AIS) thrombi retrieved by mechanical thrombectomy from 500 patients and data of clot length by CTA/NCCT were collected from three hospitals in Europe. ECA was obtained by measuring the area of the extracted clot. Non-parametric tests were used for data analysis. Results: A strong positive correlation was found between clot length on CTA/NCCT and ECA (rho = 0.619,N = 500, P < 0.0001*). Vessel size influences clot length on CTA/NCCT (H2 = 98.6, P < 0.0001*) and ECA (H2 = 105.6,P < 0.0001*), but the significant correlation between CTA/NCCT length and ECA was evident in all vessels. Poorer revascularisation outcome was associated with more passes (H5 = 73.1, P < 0.0001*). More passes were required to remove longer clots (CTA/NCCT; H4 = 31.4, P < 0.0001*; ECA; H4 = 50.2, P < 0.0001*). There was no significant main association between recanalization outcome and length on CTA/NCCT or ECA, but medium sized clots (ECA 20-40 mm(2)) were associated with least passes and highest revascularisation outcome (N = 500, X-2 = 16.2, P < 0.0001*). Conclusion: Clot length on CTA/NCCT strongly correlates with ECA. Occlusion location influences clot size. More passes are associated with poorer revascularisation outcome and bigger clots. The relationship between size and revascularisation outcome is more complex. Clots of medium ECA take less passes to remove and are associated with better recanalization outcome than both smaller and larger clots.
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30.
  • Rossi, Rosanna, et al. (författare)
  • Does prior administration of rtPA influence acute ischemic stroke clot composition? Findings from the analysis of clots retrieved with mechanical thrombectomy from the RESTORE registry.
  • 2022
  • Ingår i: Journal of neurology. - : Springer Science and Business Media LLC. - 1432-1459 .- 0340-5354. ; 269:4, s. 1913-1920
  • Tidskriftsartikel (refereegranskat)abstract
    • There is still much debate whether bridging-therapy [intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT)] might be beneficial compared to MT alone. We investigated the effect of IVT on size and histological composition of the clots retrieved from patients undergoing bridging-therapy or MT alone.We collected mechanically extracted thrombi from 1000 acute ischemic stroke (AIS) patients included in RESTORE registry. Patients were grouped according to the administration (or not) of IVT before thrombectomy. Gross photos of each clot were taken and Extracted Clot Area (ECA) was measured using ImageJ software. Martius Scarlett Blue stain was used to characterize the main histological clot components [red blood cells (RBCs), fibrin (FIB), platelets/other (PTL)] and Orbit Image Analysis was used for quantification. Additionally, we calculated the area of each main component by multiplying the component percent by ECA. Chi-squared and Kruskal-Wallis tests were used for statistical analysis.451 patients (45%) were treated with bridging-therapy while 549 (55%) underwent MT alone. When considering only percent histological composition, we did not find any difference in RBC% (P=0.895), FIB% (P=0.458) and PTL% (P=0.905). However, bridging-therapy clots were significantly smaller than MT-alone clots [32.7 (14.8-64.9) versus 36.8 (20.1-79.8) mm2, N=1000, H1=7.679, P=0.006*]. A further analysis expressing components per clot area showed that clots retrieved from bridging-therapy cases contained less RBCs [13.25 (4.29-32.06) versus 14.97 (4.93-39.80) mm2, H1=3.637, P=0.056] and significantly less fibrin [9.10 (4.62-17.98) versus 10.54 (5.57-22.48) mm2, H1=7.920, P=0.005*] and platelets/other [5.04 (2.26-11.32) versus 6.54 (2.94-13.79) mm2, H1=9.380, P=0.002*] than MT-alone clots.Our results suggest that previous IVT administration significantly reduces thrombus size, proportionally releasing all the main histological components.
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31.
  • Rossi, Rosanna, et al. (författare)
  • Investigating the Role of Brain Natriuretic Peptide (BNP) and N-Terminal-proBNP in Thrombosis and Acute Ischemic Stroke Etiology.
  • 2024
  • Ingår i: International Journal of Molecular Sciences. - 1661-6596 .- 1422-0067. ; 25:5
  • Tidskriftsartikel (refereegranskat)abstract
    • The need for biomarkers for acute ischemic stroke (AIS) to understand the mechanisms implicated in pathological clot formation is critical. The levels of the brain natriuretic peptides known as brain natriuretic peptide (BNP) and NT-proBNP have been shown to be increased in patients suffering from heart failure and other heart conditions. We measured their expression in AIS clots of cardioembolic (CE) and large artery atherosclerosis (LAA) etiology, evaluating their location inside the clots, aiming to uncover their possible role in thrombosis. We analyzed 80 thrombi from 80 AIS patients in the RESTORE registry of AIS clots, 40 of which were of CE and 40 of LAA etiology. The localization of BNP and NT-BNP, quantified using immunohistochemistry and immunofluorescence, in AIS-associated white blood cell subtypes was also investigated. We found a statistically significant positive correlation between BNP and NT-proBNP expression levels (Spearman's rho = 0.668 p < 0.0001 *). We did not observe any statistically significant difference between LAA and CE clots in BNP expression (0.66 [0.13-3.54]% vs. 0.53 [0.14-3.07]%, p = 0.923) or in NT-proBNP expression (0.29 [0.11-0.58]% vs. 0.18 [0.05-0.51]%, p = 0.119), although there was a trend of higher NT-proBNP expression in the LAA clots. It was noticeable that BNP was distributed throughout the thrombus and especially within platelet-rich regions. However, NT-proBNP colocalized with neutrophils, macrophages, and T-lymphocytes, suggesting its association with the thrombo-inflammatory process.
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32.
  • Rossi, R., et al. (författare)
  • Potential Biomarkers of Acute Ischemic Stroke Etiology Revealed by Mass Spectrometry-Based Proteomic Characterization of Formalin-Fixed Paraffin-Embedded Blood Clots
  • 2022
  • Ingår i: Frontiers in Neurology. - : Frontiers Media SA. - 1664-2295. ; 13
  • Tidskriftsartikel (refereegranskat)abstract
    • Background and Aims: Besides the crucial role in the treatment of acute ischemic stroke (AIS), mechanical thrombectomy represents a unique opportunity for researchers to study the retrieved clots, with the possibility of unveiling biological patterns linked to stroke pathophysiology and etiology. We aimed to develop a shotgun proteomic approach to study and compare the proteome of formalin-fixed paraffin-embedded (FFPE) cardioembolic and large artery atherosclerotic (LAA) clots. Methods: We used 16 cardioembolic and 15 LAA FFPE thrombi from 31 AIS patients. The thrombus proteome was analyzed by label-free quantitative liquid chromatography-tandem mass spectrometry (LC-MS/MS). MaxQuant v1.5.2.8 and Perseus v.1.6.15.0 were used for bioinformatics analysis. Protein classes were identified using the PANTHER database and the STRING database was used to predict protein interactions. Results: We identified 1,581 protein groups as part of the AIS thrombus proteome. Fourteen significantly differentially abundant proteins across the two etiologies were identified. Four proteins involved in the ubiquitin-proteasome pathway, blood coagulation or plasminogen activating cascade were identified as significantly abundant in LAA clots. Ten proteins involved in the ubiquitin proteasome-pathway, cytoskeletal remodeling of platelets, platelet adhesion or blood coagulation were identified as significantly abundant in cardioembolic clots. Conclusion: Our results outlined a set of 14 proteins for a proof-of-principle characterization of cardioembolic and LAA FFPE clots, advancing the proteome profile of AIS human thrombi and understanding the pathophysiology of ischemic stroke.
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33.
  • Rossi, Rosanna, et al. (författare)
  • S100b in acute ischemic stroke clots is a biomarker for post-thrombectomy intracranial hemorrhages.
  • 2022
  • Ingår i: Frontiers in neurology. - : Frontiers Media SA. - 1664-2295. ; 13
  • Tidskriftsartikel (refereegranskat)abstract
    • Post-thrombectomy intracranial hemorrhages (PTIH) are dangerous complications of acute ischemic stroke (AIS) following mechanical thrombectomy. We aimed to investigate if S100b levels in AIS clots removed by mechanical thrombectomy correlated to increased risk of PTIH.We analyzed 122 thrombi from 80 AIS patients in the RESTORE Registry of AIS clots, selecting an equal number of patients having been pre-treated or not with rtPA (40 each group). Within each subgroup, 20 patients had developed PTIH and 20 patients showed no signs of hemorrhage. Gross photos of each clot were taken and extracted clot area (ECA) was measured using ImageJ. Immunohistochemistry for S100b was performed and Orbit Image Analysis was used for quantification. Immunofluorescence was performed to investigate co-localization between S100b and T-lymphocytes, neutrophils and macrophages. Chi-square or Kruskal-Wallis test were used for statistical analysis.PTIH was associated with higher S100b levels in clots (0.33 [0.08-0.85] vs. 0.07 [0.02-0.27] mm2, H1 = 6.021, P = 0.014*), but S100b levels were not significantly affected by acute thrombolytic treatment (P = 0.386). PTIH was also associated with patients having higher NIHSS at admission (20.0 [17.0-23.0] vs. 14.0 [10.5-19.0], H1 = 8.006, P = 0.005) and higher number of passes during thrombectomy (2 [1-4] vs. 1 [1-2.5], H1 = 5.995, P = 0.014*). S100b co-localized with neutrophils, macrophages and with T-lymphocytes in the clots.Higher S100b expression in AIS clots, higher NIHSS at admission and higher number of passes during thrombectomy are all associated with PTIH. Further investigation of S100b expression in AIS clots by neutrophils, macrophages and T-lymphocytes could provide insight into the role of S100b in thromboinflammation.
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34.
  • Rossi, R., et al. (författare)
  • The administration of rtPA before mechanical thrombectomy in acute ischemic stroke patients is associated with a significant reduction of the retrieved clot area but it does not influence revascularization outcome
  • 2021
  • Ingår i: Journal of Thrombosis and Thrombolysis. - : Springer Science and Business Media LLC. - 0929-5305 .- 1573-742X. ; 51:2, s. 545-551
  • Tidskriftsartikel (refereegranskat)abstract
    • Both intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are evidence-based treatments for acute ischemic stroke (AIS) in selected cases. Recanalization may occur following IVT without the necessity of further interventions or requiring a subsequent MT procedure. IVT prior to MT (bridging-therapy) may be associated with benefits or hazards. We studied the retrieved clot area and degree of recanalization in patients undergoing MT or bridging-therapy for whom it was possible to collect thrombus material. We collected mechanically extracted thrombi from 550 AIS patients from four International stroke centers. Patients were grouped according to the administration (or not) of IVT before thrombectomy and the mechanical thrombectomy approach used. We assessed the number of passes for clot removal and the mTICI (modified Treatment In Cerebral Ischemia) score to define revascularization outcome. Gross photos of each clot were taken and the clot area was measured with ImageJ software. The non-parametric Kruskal-Wallis test was used for statistical analysis. 255 patients (46.4%) were treated with bridging-therapy while 295 (53.6%) underwent MT alone. By analysing retrieved clot area, we found that clots from patients treated with bridging-therapy were significantly smaller compared to those from patients that underwent MT alone (H-1 = 10.155 p = 0.001*). There was no difference between bridging-therapy and MT alone in terms of number of passes or final mTICI score. Bridging-therapy was associated with significantly smaller retrieved clot area compared to MT alone but it did not influence revascularization outcome.
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35.
  • Samuelsson, Jennifer, et al. (författare)
  • Intra-arterial nimodipine for severe cerebral vasospasm after aneurysmal subarachnoid haemorrhage - neurological and radiological outcome.
  • 2022
  • Ingår i: The neuroradiology journal. - : SAGE Publications. - 2385-1996 .- 1971-4009. ; 35:2, s. 213-219
  • Tidskriftsartikel (refereegranskat)abstract
    • Cerebral vasospasm is a known complication to aneurysmal subarachnoid haemorrhage, which can lead to severe morbidity. Intra-arterial vasodilation therapy is widely used as a last resort treatment in patients with symptomatic refractory cerebral vasospasm but there is limited data about the outcome. The purpose of this study is to evaluate the neurological and radiological outcome in patients treated with intra-arterial nimodipine in relation to cerebral infarction, procedure-related complications and clinical outcome.Patients with refractory cerebral vasospasm treated with intra-arterial nimodipine during 2009-2020 at Sahlgrenska University Hospital were retrospectively reviewed. Neurological outcome (modified Rankin Scale) at 30 days and 6 months, development of cerebral infarction after intra-arterial nimodipine treatment and procedure-related complications were studied.Forty-eight patients were treated with intra-arterial nimodipine. A good outcome (modified Rankin Scale 0-2) was seen in 25% (n=12) of the patients after 30 days and in 47% (n=22) of the patients after six months. Infarction related to the vasospastic vessel after treatment with intra-arterial nimodipine was seen in 60% (n=29) of the patients. A total of 124 procedures with intra-arterial nimodipine were performed where complications were seen in 10 (21%) patients in 10 (8%) procedures. Four (8%) patients died within 30 days.A majority of patients developed an ischaemic cerebral infarction in spite of intra-arterial nimodipine treatment. However, a good clinical recovery was seen in almost half of the patients after 6 months. Minor complications occurred in one out of five patients.
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36.
  • Samuelsson, Jennifer, et al. (författare)
  • Neurological outcome, mental fatigue and occurrence of aneurysms more than 15 years after aneurysmal subarachnoid haemorrhage.
  • 2021
  • Ingår i: World neurosurgery. - : Elsevier BV. - 1878-8769 .- 1878-8750. ; 151
  • Tidskriftsartikel (refereegranskat)abstract
    • Long-term data on neurological and radiological outcome after aneurysmal subarachnoid haemorrhage (aSAH) is scarce. The aims of this study were to report neurological and radiological outcome more than 15 years after aSAH.Patients from Western Sweden with aSAH randomized to endovascular (EVT) or microsurgical treatment (MST) from 1997 to 2001 were included. Main end-points were neurological outcome assessed by modified Rankin scale (mRS), fatigue assessed by mental fatigue scale (MFS) and radiological outcome assessed by magnetic resonance angiography (MRA). Results were compared to a control group for MFS.Forty-six patients (62.2%) of the 74 survivors replied after 15-21 years. Eighteen had MST and 28 had EVT. mRS 0-2 was found in 100% of EVT patients and in 88.8 % of MST patients. Moderate or severe mental fatigue was found in 7/28 patients (25 %) in the EVT group and 7/18 patients (38.8 % (p<0.05)) in the MST group, whereas moderate or severe mental fatigue was observed in 3/34 (8.9 %) in the control group. Twenty-nine patients agreed to do an MRA. In the EVT group, new neck remnants were found in 2/16 (12.5%) and de novo aneurysm was found in 2/16 (12.5%). In the MST group de novo aneurysm was found in 1/13 (7.7%).Neurological outcome at long-term follow-up after aSAH was good, however mental fatigue was overrepresented compared to healthy controls, regardless of treatment modality. Residual or de novo aneurysm was found in 17% of patients warranting radiological long-term follow-up.
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37.
  • Samuelsson, Jennifer, et al. (författare)
  • Risk of de novo aneurysm formation in patients previously diagnosed with a ruptured or unruptured aneurysm: 18-year follow-up.
  • 2023
  • Ingår i: Clinical neurology and neurosurgery. - 0303-8467 .- 1872-6968. ; 233
  • Tidskriftsartikel (refereegranskat)abstract
    • Data on de novo aneurysm formation after treatment for intracranial aneurysms remains scarce. We studied the incidence of de novo aneurysm formation in patients who had undergone aneurysm treatment more than 18 years prior to follow-up. As it is a disease affecting a younger patient population more specific guidelines are needed when planning a follow-up regime.The rate of de novo aneurysm formation was assessed with Magnetic Resonance Angiography (MRA) follow-up >18 years after endovascular or microsurgical treatment for an intracranial aneurysm. Variables associated with de novo aneurysm formation were studied using logistic regression. Missing data were imputed using chained random forests. A data-driven model for the prediction of de novo aneurysm was created to calculate the relative variable importance of ten clinical features.De novo aneurysms were identified in 11/81 (13.6 %) patients, of whom 1 was male, over a median follow-up of 20 years. Sex was the most important variable associated with de novo aneurysm formation. Regarding the development of de novo aneurysm, men displayed an odds ratio (OR) of 0.16 (0.01-0.97), compared with women. OR for mRS score 2 or more was 0.20 (95 % CI 0.01-1.34), and OR for smokers was 3.70 (0.54-31.18). Six out of 11 patients (54.5 %) needed treatment; 1 underwent endovascular treatment (EVT) and 5 underwent microsurgical treatment (MST). The overall annual de novo aneurysm formation rate was 0.92 %.This study highlights the need for a longer follow-up imaging monitoring of patients that have previously undergone treatment for an intracranial aneurysm. These data are useful to take into consideration when planning a follow-up strategy.
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38.
  • Schönenberger, Silvia, et al. (författare)
  • Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy: A Systematic Review and Meta-analysis.
  • 2019
  • Ingår i: JAMA. - : American Medical Association (AMA). - 1538-3598 .- 0098-7484. ; 322:13, s. 1283-1293
  • Tidskriftsartikel (refereegranskat)abstract
    • General anesthesia during thrombectomy for acute ischemic stroke has been associated with poor neurological outcome in nonrandomized studies. Three single-center randomized trials reported no significantly different or improved outcomes for patients who received general anesthesia compared with procedural sedation.To detect differences in functional outcome at 3 months between patients who received general anesthesia vs procedural sedation during thrombectomy for anterior circulation acute ischemic stroke.MEDLINE search for English-language articles published from January 1, 1980, to July 31, 2019.Randomized clinical trials of adults with a National Institutes of Health Stroke Scale score of at least 10 and anterior circulation acute ischemic stroke assigned to receive general anesthesia or procedural sedation during thrombectomy.Individual patient data were obtained from 3 single-center, randomized, parallel-group, open-label treatment trials with blinded end point evaluation that met inclusion criteria and were analyzed using fixed-effects meta-analysis.Degree of disability, measured via the modified Rankin Scale (mRS) score (range 0-6; lower scores indicate less disability), analyzed with the common odds ratio (cOR) to detect the ordinal shift in the distribution of disability over the range of mRS scores.A total of 368 patients (mean [SD] age, 71.5 [12.9] years; 163 [44.3%] women; median [interquartile range] National Institutes of Health Stroke Scale score, 17 [14-21]) were included in the analysis, including 183 (49.7%) who received general anesthesia and 185 (50.3%) who received procedural sedation. The mean 3-month mRS score was 2.8 (95% CI, 2.5-3.1) in the general anesthesia group vs 3.2 (95% CI, 3.0-3.5) in the procedural sedation group (difference, 0.43 [95% CI, 0.03-0.83]; cOR, 1.58 [95% CI, 1.09-2.29]; P=.02). Among prespecified adverse events, only hypotension (decline in systolic blood pressure of more than 20% from baseline) (80.8% vs 53.1%; OR, 4.26 [95% CI, 2.55-7.09]; P<.001) and blood pressure variability (systolic blood pressure >180 mm Hg or <120 mm Hg) (79.7 vs 62.3%; OR, 2.42 [95% CI, 1.49-3.93]; P<.001) were significantly more common in the general anesthesia group.Among patients with acute ischemic stroke involving the anterior circulation undergoing thrombectomy, the use of protocol-based general anesthesia, compared with procedural sedation, was significantly associated with less disability at 3 months. These findings should be interpreted tentatively, given that the individual trials examined were single-center trials and disability was the primary outcome in only 1 trial.
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39.
  • Simonsen, C Z, et al. (författare)
  • Patients Requiring Conversion to General Anesthesia during Endovascular Therapy Have Worse Outcomes: A Post Hoc Analysis of Data from the SAGA Collaboration.
  • 2020
  • Ingår i: AJNR. American journal of neuroradiology. - 1936-959X. ; 41:12, s. 2298-2302
  • Tidskriftsartikel (refereegranskat)abstract
    • Endovascular therapy for acute ischemic stroke is often performed with the patient under conscious sedation. Emergent conversion from conscious sedation to general anesthesia is sometimes necessary. The aim of this study was to assess the functional outcome in converted patients compared with patients who remained in conscious sedation and to identify predictors associated with the risk of conversion.Data from 368 patients, included in 3 trials randomizing between conscious sedation and general anesthesia before endovascular therapy (SIESTA, ANSTROKE, and GOLIATH) constituted the study cohort. Twenty-one (11%) of 185 patients randomized to conscious sedation were emergently converted to general anesthesia.Absence of hyperlipidemia seemed to be the strongest predictor of conversion to general anesthesia, albeit a weak predictor (area under curve = 0.62). Sex, hypertension, diabetes, smoking status, atrial fibrillation, blood pressure, size of the infarct, and level and side of the occlusion were not significantly associated with conversion to general anesthesia. Neither age (mean age, 71.3 ± 13.8 years for conscious sedation versus 71.6 ± 12.3 years for converters, P=.58) nor severity of stroke (mean NIHSS score, 17 ± 4 versus 18 ± 4, respectively, P=.27) were significantly different between converters and those who tolerated conscious sedation. The converters had significantly worse outcome with a common odds ratio of 2.67 (P=.015) for a shift toward a higher mRS score compared with the patients remaining in the conscious sedation group.Patients undergoing conversion had significantly worse outcome compared with patients remaining in conscious sedation. No factor was identified that predicted conversion from conscious sedation to general anesthesia.
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40.
  • Strambo, Davide, et al. (författare)
  • Effect of Asymptomatic and Symptomatic COVID-19 on Acute Ischemic Stroke Revascularization Outcomes.
  • 2024
  • Ingår i: Stroke. - 0039-2499. ; 55:1, s. 78-88
  • Tidskriftsartikel (refereegranskat)abstract
    • The association of COVID-19 with higher bleeding risk and worse outcomes in acute ischemic stroke (AIS) undergoing revascularization may be related to the presence of infection symptoms. We aimed to assess the safety and outcomes of revascularization treatments in patients with AIS with asymptomatic COVID-19 (AS-COVID) or symptomatic COVID-19 (S-COVID).We conducted an international multicenter retrospective cohort study of consecutive AIS tested for SARS-CoV-2, receiving intravenous thrombolysis and endovascular treatment between 2020 and 2021. We compared COVID-negative controls, AS-COVID, and S-COVID using multivariable regression. We assessed symptomatic intracranial hemorrhage (symptomatic intracerebral hemorrhage), mortality, and 3-month disability (modified Rankin Scale score).Among 15124 patients from 105 centers (median age, 71 years; 49% men; 39% treated with intravenous thrombolysis only; and 61% with endovascular treatment±intravenous thrombolysis), 849 (5.6%) had COVID-19, of whom 395 (46%) were asymptomatic and 454 (54%) symptomatic. Compared with controls, both patients with AS-COVID and S-COVID had higher symptomatic intracerebral hemorrhage rates (COVID-controls, 5%; AS-COVID, 7.6%; S-COVID, 9.4%; adjusted odds ratio [aOR], 1.43 [95% CI, 1.03-1.99]; aOR, 1.63 [95% CI, 1.14-2.32], respectively). Only in patients with symptomatic infections, we observed a significant increase in mortality at 24 hours (COVID-controls, 1.3%; S-COVID, 4.8%; aOR, 2.97 [95% CI, 1.76-5.03]) and 3 months (COVID-controls, 19.5%; S-COVID, 40%; aOR, 2.64 [95% CI, 2.06-3.37]). Patients with COVID-19 had worse 3-month disability regardless of disease symptoms although disability was affected to a greater extent in symptomatic patients (aOR for worse modified Rankin Scale score shift: AS-COVID, 1.25 [95% CI, 1.03-1.51]; S-COVID, 2.10 [95% CI, 1.75-2.53]). S-COVID had lower successful recanalization (74.9% versus 85.6%; P<0.001), first pass recanalization (20.3% versus 28.3%; P=0.005), and a higher number of passes.In AIS undergoing revascularization treatments, both AS-COVID and S-COVID influence the risk of intracranial bleeding and worse clinical outcomes. The magnitude of this effect is more pronounced in symptomatic infections, which also present less favorable recanalization outcomes. These findings emphasize the impact of SARS-CoV-2 infection on the prognosis of revascularized AIS independent of symptom status.URL: https://www.clinicaltrials.gov; Unique identifier: NCT04895462.
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41.
  • Wikholm, Gunnar, 1948, et al. (författare)
  • Interventionell neuroradiologi vid ischemisk stroke
  • 2014
  • Ingår i: Stroke och cerebrovaskulär sjukdom. - Lund : Studentlitteratur. - 9789144086583 ; , s. 205-218
  • Bokkapitel (övrigt vetenskapligt/konstnärligt)abstract
    • Stroke och cerebrovaskulär sjukdom Stroke är den tredje vanligaste dödsorsaken i Sverige och den vanligaste somatiska orsaken till funktionsnedsättning hos vuxna, och därmed en av våra allvarligaste folksjukdomar. Denna bok ger en bred översikt över epidemiologi, anatomisk och fysiologisk bakgrund, profylax, farmakologiska och interventionella behandlingsstrategier och prognos vid stroke och cerebrovaskulär sjukdom. I denna andra upplaga har materialet angående strokesjukdomens olika komplikationer och rehabilitering efter stroke fördjupats. Nya kapitel om primärprevention, TIA, dissektioner, ovanliga stroketyper, emotionella reaktioner, kognitiv vaskulär svikt samt bilkörning efter stroke har tillkommit. Uppdaterade och utförliga beskrivningar ges av behandlingsformer, prevention, trombolys, interventionell kateterbehandling, endovaskulär stentning samt öppen kirurgi. Boken riktar sig till alla som är inblandade i behandling och vård av strokepatienter, i första hand specialister inom den öppna och slutna vården, men även till dem som handlägger dessa patienter mer sällan eller är under utbildning.
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42.
  • Woock, Malin, et al. (författare)
  • Cancer and stroke: commonly encountered by clinicians, but little evidence to guide clinical approach.
  • 2022
  • Ingår i: Therapeutic advances in neurological disorders. - : SAGE Publications. - 1756-2856 .- 1756-2864. ; 15
  • Tidskriftsartikel (refereegranskat)abstract
    • The association between stroke and cancer is well-established. Because of an aging population and longer survival rates, the frequency of synchronous stroke and cancer will become even more common. Different pathophysiologic mechanisms have been proposed how cancer or cancer treatment directly or via coagulation disturbances can mediate stroke. Increased serum levels of D-dimer, fibrin degradation products, and CRP are more often seen in stroke with concomitant cancer, and the clot retrieved during thrombectomy has a more fibrin- and platelet-rich constitution compared with that of atherosclerotic etiology. Multiple infarctions are more common in patients with active cancer compared with those without a cancer diagnosis. New MRI techniques may help in detecting typical patterns seen in the presence of a concomitant cancer. In ischemic stroke patients, a newly published cancer probability score can help clinicians in their decision-making when to suspect an underlying malignancy in a stroke patient and to start cancer-screening studies. Treating stroke patients with synchronous cancer can be a delicate matter. Limited evidence suggests that administration of intravenous thrombolysis appears safe in non-axial intracranial and non-metastatic cancer patients. Endovascular thrombectomy is probably rather safe in these patients, but probably futile in most patients placed on palliative care due to their advanced disease. In this topical review, we discuss the epidemiology, pathophysiology, and prognosis of ischemic and hemorrhagic strokes as well as cerebral venous thrombosis and concomitant cancer. We further summarize the current evidence on acute management and secondary preventive therapy.
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