Joanna Schaafsma - Independent Researcher (original) (raw)
Papers by Joanna Schaafsma
Abstract P473: Perfusion Imaging Identifies Patients With Mild Deficits Due to Large Vessel Occlusion Who May Benefit From Endovascular Thrombectomy: A Pooled International Cohort Study
Stroke, 2021
Background: Efficacy and safety of endovascular thrombectomy (EVT) in large vessel occlusion (LVO... more Background: Efficacy and safety of endovascular thrombectomy (EVT) in large vessel occlusion (LVO) patients with mild deficits is unclear. Methods: Pooled cohort of pts with mild deficits (NIHSS<6) due to (ICA, M1, M2) LVO from EXTEND IA TNK I & II RCTs and prospective data from 12 centers (US, AUS, NZ, Canada, Spain) from 1/2013 to 2/2020 was divided into medical management (MM) vs EVT. All pts had baseline CT, CTA, CTPRAPID software estimated ischemic core and mismatch. Pts stratified into with or without target profile (≥1cc core / mismatch ratio ≥ 1.8 / mismatch volume ≥ 15cc). Primary outcome- excellent (90 day mRS 0-1); Secondary- mRS shift, safety (sICH, neuro-worsening, mortality). Results: Of 371 pts, 189 (51%) had EVT. Time LKW to EVT center: EVT 165 (70- 416) vs MM 200 (72-564) min, p=0.35 were similar. EVT pts had larger perfusion lesions (51 cc (23-86) vs 30.1 (5, 65), p<0.001), higher NIHSS 4 (2-5) vs 3 (2-4), p=0.009), less IV tPA (30% vs 41%, p=0.044), more M1s...
Sex differences in endovascular thrombectomy outcomes in large vessel occlusion: a propensity-matched analysis from the SELECT study
Journal of NeuroInterventional Surgery, 2022
BackgroundSex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysi... more BackgroundSex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysis. Despite several studies, there is still a lack of consensus on whether endovascular thrombectomy (EVT) outcomes differ between men and women.ObjectiveTo compare sex differences in EVT outcomes at 90-day follow-up and assess whether progression in functional status from discharge to 90-day follow-up differs between men and women.MethodsFrom the Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) prospective cohort study (2016–2018), adult men and women (≥18 years) with anterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery M1/M2) treated with EVT up to 24 hours from last known well were matched using propensity scores. Discharge and 90-day modified Rankin Scale (mRS) scores were compared between men and women. Furthermore, we evaluated the improvement in mRS scores from discharge to 90 days in men and women using a repeated-measu...
Supplemental material, ONLINE_SUPPLEMENT for Outcome, efficacy and safety of endovascular thrombe... more Supplemental material, ONLINE_SUPPLEMENT for Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry by Thomas Raphael Meinel, Johannes Kaesmacher, Pasquale Mordasini, Pascal J. Mosimann, Simon Jung, Marcel Arnold, Mirjam Rachel Heldner, Patrik Michel, Steven D. Hajdu, Marc Ribo, Manuel Requena, Christian Maegerlein, Benjamin Friedrich, Vincent Costalat, Amel Benali, Laurent Pierot, Matthias Gawlitza, Joanna Schaafsma, Vitor Mendes Pereira, Jan Gralla and Urs Fischer in Therapeutic Advances in Neurological Disorders
JAMA Network Open, 2021
IMPORTANCE Some patients have poor outcomes despite small infarcts after endovascular therapy (EV... more IMPORTANCE Some patients have poor outcomes despite small infarcts after endovascular therapy (EVT), while others with large infarcts do well. Understanding why these discrepancies occur may help to optimize EVT outcomes. OBJECTIVE To validate exploratory findings from the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial regarding pretreatment, treatment-related, and posttreatment factors associated with discrepancies between follow-up infarct volume (FIV) and 90-day functional outcome. DESIGN, SETTING, AND PARTICIPANTS This cohort study is a post hoc analysis of the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, a double-blind, randomized, placebo-controlled, international, multicenter trial conducted from March 2017 to August 2019. Patients who participated in ESCAPE-NA1 and had available 90-day modified Rankin Scale (mRS) scores and 24-hour to 48-hour posttreatment follow-up parenchymal imaging were included. EXPOSURES Small FIV (volume Յ25th percentile) and large FIV (volume Ն75th percentile) on 24-hour computed tomography/magnetic resonance imaging. Baseline factors, outcomes, treatments, and poststroke serious adverse events (SAEs) were compared between discrepant cases (ie, patients with 90-day mRS score Ն3 despite small FIV or those with mRS scores Յ2 despite large FIV) and nondiscrepant cases. MAIN OUTCOMES AND MEASURES Area under the curve (AUC) and goodness of fit of prespecified logistic models, including pretreatment (eg, age, cancer, vascular risk factors) and treatment-related and posttreatment (eg, SAEs) factors, were compared with stepwise regression-derived models for ability to identify small FIV with higher mRS score and large FIV with lower mRS score. RESULTS Among 1091 patients (median [IQR] age, 70.8 [60.8-79.8] years; 549 [49.7%] women; median [IQR] FIV, 24.9 mL [6.6-92.2 mL]), 42 of 287 patients (14.6%) with FIV of 7 mL or less (ie, Յ25th percentile) had an mRS score of at least 3; 65 of 275 patients (23.6%) with FIV of 92 mL or greater (ie, Ն75th percentile) had an mRS score of 2 or less. Prespecified models of pretreatment factors (ie, age, cancer, vascular risk factors) associated with low FIV and higher mRS score performed similarly to models selected by stepwise regression (AUC, 0.92 [95% CI, 0.89-0.95] vs 0.93 [95% CI, 0.90-0.95]; P = .42). SAEs, specifically infarct in new territory, recurrent stroke, pneumonia, and congestive heart failure, were associated with low FIV and higher mRS scores; stepwise models also identified 24-hour hemoglobin as treatment-related/posttreatment factor (continued) Key Points Question Why do some patients have poor outcomes despite small infarcts after endovascular therapy, while others with large infarcts fare better? Findings In this cohort study of 1091 patients who received endovascular therapy as part of a randomized clinical trial, discrepancies between infarct volume and functional outcome were associated with prespecified pretreatment factors, such as age, cancer, and vascular risk factors, as well as posttreatment factors, such as infarct in new territory, stroke progression, intracerebral hemorrhage, recurrent stroke, pneumonia, and heart failure. Models including these factors performed similar to those derived from stepwise regressions. Meaning In this study, discrepancies between outcome and infarct volume were associated with pretreatment and posttreatment factors, including complications related to index stroke evolution, secondary prevention, and quality of stroke unit care.
Bridging May Increase the Risk of Symptomatic Intracranial Hemorrhage in Thrombectomy Patients With Low Alberta Stroke Program Early Computed Tomography Score
Stroke, 2021
Background and Purpose: Whether intravenous thrombolysis (IVT) increases the risk for symptomatic... more Background and Purpose: Whether intravenous thrombolysis (IVT) increases the risk for symptomatic intracranial hemorrhage (sICH) in patients treated with mechanical thrombectomy (MT) is a matter of debate. Purpose of this study was to evaluate the extent of early ischemia as a possible factor influencing the risk for sICH after IVT+MT versus direct MT. Methods: An explorative analysis of the BEYOND-SWIFT (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy) multicenter cohort was performed. We hypothesized that the sICH risk between IVT+MT versus direct MT differs across the strata of Alberta Stroke Program Early CT Scores (ASPECTS). For this purpose, all patients with ICA, M1, and M2 vessel occlusions and available noncontrast computed tomography or diffusion-weighed imaging ASPECTS (n=2002) were analyzed. We used logistic regression analysis in subgroups,...
SELECTion criteria for large core trials: dogma or data?
Journal of NeuroInterventional Surgery, 2021
Sarraj A, et al. J NeuroIntervent Surg Month 2021 Vol 0 Selection criteria for large core trials:... more Sarraj A, et al. J NeuroIntervent Surg Month 2021 Vol 0 Selection criteria for large core trials: dogma or data? Amrou Sarraj , Bruce Campbell, Marc Ribo , Muhammad Shazam Hussain , Michael Chen , Michael G Abraham, Maarten G Lansberg, Vitor Mendes Pereira , Spiros Blackburn, Clark W Sitton, Ronald F Budzik, Natalia Pérez de la Ossa, Juan F Arenillas, Teddy Wu , Jordi Blasco, Michael Mullen, Joanna Schaafsma, Jenny P Tsai, Navdeep Sangha, Osman Kozak, Daniel Gibson, Steven Warach, Dennis Cordato, Nathan W Manning , Timothy J Kleinig, JeanMarc Olivot , Lucas Elijovich , Georgios Tsivgoulis, Andrei Alexandrov, Pascal Jabbour , Bernard Yan, Scott E Kasner, Adam S Arthur , Mark Parsons, James C Grotta, Ameer E Hassan , Gregory W Albers, On behalf of SELECT2 Investigators and SELECT2 Steering Committee
Journal of neurosurgical anesthesiology, Jan 31, 2018
Anesthetic modality and hemodynamic management during mechanical thrombectomy (MT) for acute isch... more Anesthetic modality and hemodynamic management during mechanical thrombectomy (MT) for acute ischemic stroke (AIS) are potential contributors to the success of revascularization. The aims of our study were to review the hemodynamic management by anesthesiologists and clinical outcomes in patients undergoing MT under conscious sedation. Retrospective cohort study of patients with anterior circulation AIS from January 2012 to March 2016. Primary outcome was hemodynamic intervention, defined as administration of vasoactive drugs to maintain systolic blood pressure (BP) between 140 and 180 mm Hg. The secondary outcome was poor hemodynamic control, defined as BP outside target for >15 minutes despite hemodynamic intervention. We performed regression analysis to determine the predictors of hemodynamic intervention and poor hemodynamic control. A total of 126 patients were included in this study; 92% (116) receiving conscious sedation and 8% (10) no sedation. Upon arrival to the neurora...
Journal of the Neurological Sciences, 2003
Objectives: Patients with Parkinson's disease (PD) have an increased risk of falling that has yet... more Objectives: Patients with Parkinson's disease (PD) have an increased risk of falling that has yet to be fully explained. To better understand the gait disturbance in PD and the factors that contribute to falls, we quantitatively evaluated: (1) the relationship between gait variability (a marker of fall risk in other populations), fall history, and other parkinsonian features, and (2) the effects of levodopa on these relationships. Methods: The average stride time and stride-to-stride variability were measured using force-sensitive insoles during comfortable walking. Fall frequency, motor control, function, and mental health were measured using the Unified Parkinson's Disease Rating Scale (UPDRS), the Mini-Mental State Exam (MMSE), and the timed motor tests of the Core Assessment Program for Intracerebral Transplantations (CAPIT) in 32 subjects with idiopathic PD, in an ''off'' (unmedicated) state and again in an ''on'' (medicated) state. Results: Average stride time was not associated with any UPDRS or CAPIT measure and was similar in fallers and non-fallers in ''off'' and ''on'' states (p > 0.27). Stride time variability was significantly associated with fall frequency as well as with total scores on the CAPIT and the UPDRS, ADL abilities, and motor function. Stride time variability and falls were not related to tremor, rigidity or bradykinesia in the ''off'' state. 41% of subjects reported one or more falls. Stride time variability was 8.8 F 7.9% in fallers and 4.2 F 1.3% in non-fallers (p < 0.009). Stride time variability significantly improved in response to levodopa, both in fallers and non-fallers, but remained increased in fallers (vs. non-fallers). Conclusions: The patho-physiology responsible for impaired stride-to-stride regulation of gait timing is apparently independent of other cardinal features of PD, i.e., tremor, rigidity, or bradykinesia, but is responsive to levodopa. Stride-to-stride variability is especially impaired among PD subjects with a history of falls, suggesting, for the first time, the possibility of exaggerated impairment of internal clock function in PD fallers.
Journal of Clinical Neuroscience, 2003
Background: The pathophysiology of freezing of gait (FOG) is unclear. Objective: To assess the re... more Background: The pathophysiology of freezing of gait (FOG) is unclear. Objective: To assess the relationships between FOG and other parkinsonian features in Parkinson's disease (PD), focusing on levodopa effects. Methods: Nineteen PD patients with significant FOG in "off" were assessed while "off" and "on". Three observers independently viewed videotapes of a 130-m walk and scored FOG frequency. The Unified Parkinson's disease Rating Scale was used to evaluate clinical state. Results: FOG frequency was not correlated with other parkinsonian features in "off" and only with speech and writing in "on". Levodopa significantly decreased FOG frequency (p < 0:001). This reduction was strongly correlated with improvement of tremor (R ¼ 0:80, p < 0:01) and speech (R ¼ 0:62, p < 0:05), but not with improvement in rigidity, bradykinesia, or balance. Conclusion: Levodopa decreases FOG in PD. FOG is apparently an independent motor symptom, caused by a paroxysmal pathology that is different from that responsible for bradykinesia, rigidity or postural instability.
American Journal of Neuroradiology, 2008
BACKGROUND AND PURPOSE: The long-term fate of coiled intracranial aneurysms is largely unknown, a... more BACKGROUND AND PURPOSE: The long-term fate of coiled intracranial aneurysms is largely unknown, and prolonged imaging follow-up has been advocated. The yield of follow-up imaging in coiled aneurysms adequately occluded at 6 months is unknown. In such patients, we performed time-of-flight MR angiography (MRA) to assess the incidence and therapeutic consequences of reopening 5-11 years after coiling. MATERIALS AND METHODS: Between 1995 and 2002, 661 aneurysms in 607 patients were coiled in 3 participating centers. Six-month follow-up angiograms were obtained in 497 (75%) aneurysms, of which 316 (64%) in 297 patients were adequately occluded. Of 297 patients, 84 were excluded for various reasons and 73 could not be traced. Of 140 eligible patients, 104 (74%) with 111 aneurysms were studied with 3T MR imaging and high-resolution MRA at a mean of 6.0 years after coiling (median, 5.6 years; range, 5.0-10.6 years). RESULTS: The proportion of aneurysms with reopening was 3.6% (4/111; 95% confidence interval [CI], 1.1%-9.2%). One reopened aneurysm, which initially contained intraluminal thrombus, was additionally coiled (0.9%; 95% CI, 0.0%-5.4%).
American Journal of Neuroradiology, 2009
BACKGROUND AND PURPOSE: MR angiography (MRA) is increasingly used as a noninvasive imaging techni... more BACKGROUND AND PURPOSE: MR angiography (MRA) is increasingly used as a noninvasive imaging technique for the follow-up of coiled intracranial aneurysms. However, the need for contrast enhancement has not yet been elucidated. We compared 3D time-of-flight MRA (TOF-MRA) and contrastenhanced MRA (CE-MRA) at 3T with catheter angiography. MATERIALS AND METHODS: Sixty-seven patients with 72 aneurysms underwent TOF-MRA, CE-MRA, and catheter-angiography 6 months after coiling. Occlusion status on MRA was classified as adequate (complete and neck remnant) or incomplete by 2 independent observers. For TOF-MRA and CE-MRA, interobserver agreement, intermodality agreement, and correlation with angiography were assessed by statistics. RESULTS: Catheter-angiography revealed incomplete occlusion in 12 (17%) of the 69 aneurysms; 3 aneurysms were excluded due to MR imaging artifacts. Interobserver agreement was good for CE-MRA ( ϭ 0.77; 95% confidence interval [CI], 0.55-0.98) and very good for TOF-MRA ( ϭ 0.89; 95% CI, 0.75-1.00). Correlation of TOF-MRA and CE-MRA with angiography was good. The sensitivity of TOF-MRA and CE-MRA was 75% (95% CI, 43%-95%); the specificity of TOF-MRA was 98% (95% CI, 91%-100%) and of CE-MRA, 97% (95% CI, 88%-100%). All 5 incompletely occluded aneurysms, which were additionally treated, were correctly identified with both MRA techniques. Areas under the receiver operating characteristic curve for TOF-MRA and CE-MRA were 0.90 (95% CI, 0.79 -1.00) and 0.91 (95% CI, 0.79 -1.00). Intermodality agreement between TOF-MRA and CE-MRA was very good ( ϭ 0.83; 95% CI, 0.65-1.00), with full agreement in 66 (96%) of the 69 aneurysms. In this study, TOF-MRA and CE-MRA at 3T were equivalent in evaluating the occlusion status of intracranial aneurysms after coiling. Because TOF-MRA does not involve contrast administration, this method is preferred over CE-MRA.
Abstract TP112: Mechanism of Recurrent Stroke in Patients with Atherosclerotic Vertebrobasilar Disease in Relation to Hemodynamics
Stroke, 2017
Objectives: Patients with symptomatic atherosclerotic vertebrobasilar disease are at high risk fo... more Objectives: Patients with symptomatic atherosclerotic vertebrobasilar disease are at high risk for recurrent stroke and we have demonstrated that distal flow status is independently associated with this risk. Our aim was to assess the mechanism of recurrent strokes in these patients related to their distal flow status. Methods: Patients with symptomatic atherosclerotic vertebrobasilar disease were enrolled in a prospective longitudinal cohort study (VERiTAS) with a median follow-up of 23 months. Large-vessel flow in the posterior circulation distal to the stenosis and/or occlusion was measured on quantitative MR angiography and dichotomized into normal or low flow. Three observers, who were blinded to the distal flow status, independently reviewed the imaging done at the time of the recurrent stroke to classify the most likely stroke mechanism. Results: Ten out of 72 enrolled patients had a recurrent stroke in the posterior circulation. Four patients were determined to have embolic ...
Clinical Reasoning: A 65-Year-Old Woman With New Headache, Pulsatile Tinnitus, and Visual Disturbances
Neurology
Endovascular Treatment Versus Best Medical Therapy in Acute Ischemic Stroke Patients with Mild Symptoms
World Neurosurgery
Association of initial imaging modality and futile recanalization after thrombectomy
Neurology
ObjectiveTo test the hypothesis that selection by initial imaging modality (MRI vs CT) is associa... more ObjectiveTo test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FR) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT, NCT03496064).MethodsIn 2011 patients (49.7% female, median age 73 [61–81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FR were defined as 90 days modified Rankin Scale (mRS) 4–6 despite successful recanalization in patients selected by MRI (N = 690) and CT (N = 1,321) with a sensitivity analysis considering only patients with mRS 5–6 as futile.ResultsMRI as compared to CT resulted in similar rates of subsequent MT (aOR 1.048, 95% CI 0.677–1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4–6 including 393/1,489 (26%) FR mRS 5–6. CT based selection was associated with increased rates of futile recanalizations compared to MRI (44% [41...
Abstract WP44: Comparison of Multi-modal CT Imaging Protocols Used for Decision-Making on Endovascular Treatment in Patients With Acute Ischemic Stroke
Stroke
Per-region interobserver agreement of Alberta Stroke Program Early CT Scores (ASPECTS)
Journal of NeuroInterventional Surgery
Background and purposeThe Alberta Stroke Program Early CT Score (ASPECTS) is a commonly used scor... more Background and purposeThe Alberta Stroke Program Early CT Score (ASPECTS) is a commonly used scoring system to select patients with stroke for endovascular treatment (EVT). However, the inter- and intra-reader variability is high.ObjectiveTo determine whether the inter- and intra-reader variability is different for various regions of the ASPECTS scoring system by evaluating the interobserver variability of ASPECTS between different readers in a per-region analysis.Materials and methodsAll patients with acute ischemic stroke who proceeded to EVT in our institutions over a 4-year period were retrospectively identified from a prospectively maintained database. Images were reviewed by two experienced neuroradiologists, who recalculated the ASPECTS independently. We examined each region of the ASPECTS system to evaluate agreement between the raters in each area.Results375 patients were included. The median total ASPECTS was 9 (IQR 8–9). The most common region showing ischemic change was ...
Stroke
Background and Purpose— We aimed to determine the safety and mortality after mechanical thrombect... more Background and Purpose— We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods— In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results— Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62–82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35–4.84]...
Comparison of multimodal CT scan protocols used for decision-making on mechanical thrombectomy in acute ischemic stroke
Neuroradiology
Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial
The Lancet
Abstract P473: Perfusion Imaging Identifies Patients With Mild Deficits Due to Large Vessel Occlusion Who May Benefit From Endovascular Thrombectomy: A Pooled International Cohort Study
Stroke, 2021
Background: Efficacy and safety of endovascular thrombectomy (EVT) in large vessel occlusion (LVO... more Background: Efficacy and safety of endovascular thrombectomy (EVT) in large vessel occlusion (LVO) patients with mild deficits is unclear. Methods: Pooled cohort of pts with mild deficits (NIHSS<6) due to (ICA, M1, M2) LVO from EXTEND IA TNK I & II RCTs and prospective data from 12 centers (US, AUS, NZ, Canada, Spain) from 1/2013 to 2/2020 was divided into medical management (MM) vs EVT. All pts had baseline CT, CTA, CTPRAPID software estimated ischemic core and mismatch. Pts stratified into with or without target profile (≥1cc core / mismatch ratio ≥ 1.8 / mismatch volume ≥ 15cc). Primary outcome- excellent (90 day mRS 0-1); Secondary- mRS shift, safety (sICH, neuro-worsening, mortality). Results: Of 371 pts, 189 (51%) had EVT. Time LKW to EVT center: EVT 165 (70- 416) vs MM 200 (72-564) min, p=0.35 were similar. EVT pts had larger perfusion lesions (51 cc (23-86) vs 30.1 (5, 65), p<0.001), higher NIHSS 4 (2-5) vs 3 (2-4), p=0.009), less IV tPA (30% vs 41%, p=0.044), more M1s...
Sex differences in endovascular thrombectomy outcomes in large vessel occlusion: a propensity-matched analysis from the SELECT study
Journal of NeuroInterventional Surgery, 2022
BackgroundSex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysi... more BackgroundSex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysis. Despite several studies, there is still a lack of consensus on whether endovascular thrombectomy (EVT) outcomes differ between men and women.ObjectiveTo compare sex differences in EVT outcomes at 90-day follow-up and assess whether progression in functional status from discharge to 90-day follow-up differs between men and women.MethodsFrom the Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) prospective cohort study (2016–2018), adult men and women (≥18 years) with anterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery M1/M2) treated with EVT up to 24 hours from last known well were matched using propensity scores. Discharge and 90-day modified Rankin Scale (mRS) scores were compared between men and women. Furthermore, we evaluated the improvement in mRS scores from discharge to 90 days in men and women using a repeated-measu...
Supplemental material, ONLINE_SUPPLEMENT for Outcome, efficacy and safety of endovascular thrombe... more Supplemental material, ONLINE_SUPPLEMENT for Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry by Thomas Raphael Meinel, Johannes Kaesmacher, Pasquale Mordasini, Pascal J. Mosimann, Simon Jung, Marcel Arnold, Mirjam Rachel Heldner, Patrik Michel, Steven D. Hajdu, Marc Ribo, Manuel Requena, Christian Maegerlein, Benjamin Friedrich, Vincent Costalat, Amel Benali, Laurent Pierot, Matthias Gawlitza, Joanna Schaafsma, Vitor Mendes Pereira, Jan Gralla and Urs Fischer in Therapeutic Advances in Neurological Disorders
JAMA Network Open, 2021
IMPORTANCE Some patients have poor outcomes despite small infarcts after endovascular therapy (EV... more IMPORTANCE Some patients have poor outcomes despite small infarcts after endovascular therapy (EVT), while others with large infarcts do well. Understanding why these discrepancies occur may help to optimize EVT outcomes. OBJECTIVE To validate exploratory findings from the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial regarding pretreatment, treatment-related, and posttreatment factors associated with discrepancies between follow-up infarct volume (FIV) and 90-day functional outcome. DESIGN, SETTING, AND PARTICIPANTS This cohort study is a post hoc analysis of the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, a double-blind, randomized, placebo-controlled, international, multicenter trial conducted from March 2017 to August 2019. Patients who participated in ESCAPE-NA1 and had available 90-day modified Rankin Scale (mRS) scores and 24-hour to 48-hour posttreatment follow-up parenchymal imaging were included. EXPOSURES Small FIV (volume Յ25th percentile) and large FIV (volume Ն75th percentile) on 24-hour computed tomography/magnetic resonance imaging. Baseline factors, outcomes, treatments, and poststroke serious adverse events (SAEs) were compared between discrepant cases (ie, patients with 90-day mRS score Ն3 despite small FIV or those with mRS scores Յ2 despite large FIV) and nondiscrepant cases. MAIN OUTCOMES AND MEASURES Area under the curve (AUC) and goodness of fit of prespecified logistic models, including pretreatment (eg, age, cancer, vascular risk factors) and treatment-related and posttreatment (eg, SAEs) factors, were compared with stepwise regression-derived models for ability to identify small FIV with higher mRS score and large FIV with lower mRS score. RESULTS Among 1091 patients (median [IQR] age, 70.8 [60.8-79.8] years; 549 [49.7%] women; median [IQR] FIV, 24.9 mL [6.6-92.2 mL]), 42 of 287 patients (14.6%) with FIV of 7 mL or less (ie, Յ25th percentile) had an mRS score of at least 3; 65 of 275 patients (23.6%) with FIV of 92 mL or greater (ie, Ն75th percentile) had an mRS score of 2 or less. Prespecified models of pretreatment factors (ie, age, cancer, vascular risk factors) associated with low FIV and higher mRS score performed similarly to models selected by stepwise regression (AUC, 0.92 [95% CI, 0.89-0.95] vs 0.93 [95% CI, 0.90-0.95]; P = .42). SAEs, specifically infarct in new territory, recurrent stroke, pneumonia, and congestive heart failure, were associated with low FIV and higher mRS scores; stepwise models also identified 24-hour hemoglobin as treatment-related/posttreatment factor (continued) Key Points Question Why do some patients have poor outcomes despite small infarcts after endovascular therapy, while others with large infarcts fare better? Findings In this cohort study of 1091 patients who received endovascular therapy as part of a randomized clinical trial, discrepancies between infarct volume and functional outcome were associated with prespecified pretreatment factors, such as age, cancer, and vascular risk factors, as well as posttreatment factors, such as infarct in new territory, stroke progression, intracerebral hemorrhage, recurrent stroke, pneumonia, and heart failure. Models including these factors performed similar to those derived from stepwise regressions. Meaning In this study, discrepancies between outcome and infarct volume were associated with pretreatment and posttreatment factors, including complications related to index stroke evolution, secondary prevention, and quality of stroke unit care.
Bridging May Increase the Risk of Symptomatic Intracranial Hemorrhage in Thrombectomy Patients With Low Alberta Stroke Program Early Computed Tomography Score
Stroke, 2021
Background and Purpose: Whether intravenous thrombolysis (IVT) increases the risk for symptomatic... more Background and Purpose: Whether intravenous thrombolysis (IVT) increases the risk for symptomatic intracranial hemorrhage (sICH) in patients treated with mechanical thrombectomy (MT) is a matter of debate. Purpose of this study was to evaluate the extent of early ischemia as a possible factor influencing the risk for sICH after IVT+MT versus direct MT. Methods: An explorative analysis of the BEYOND-SWIFT (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy) multicenter cohort was performed. We hypothesized that the sICH risk between IVT+MT versus direct MT differs across the strata of Alberta Stroke Program Early CT Scores (ASPECTS). For this purpose, all patients with ICA, M1, and M2 vessel occlusions and available noncontrast computed tomography or diffusion-weighed imaging ASPECTS (n=2002) were analyzed. We used logistic regression analysis in subgroups,...
SELECTion criteria for large core trials: dogma or data?
Journal of NeuroInterventional Surgery, 2021
Sarraj A, et al. J NeuroIntervent Surg Month 2021 Vol 0 Selection criteria for large core trials:... more Sarraj A, et al. J NeuroIntervent Surg Month 2021 Vol 0 Selection criteria for large core trials: dogma or data? Amrou Sarraj , Bruce Campbell, Marc Ribo , Muhammad Shazam Hussain , Michael Chen , Michael G Abraham, Maarten G Lansberg, Vitor Mendes Pereira , Spiros Blackburn, Clark W Sitton, Ronald F Budzik, Natalia Pérez de la Ossa, Juan F Arenillas, Teddy Wu , Jordi Blasco, Michael Mullen, Joanna Schaafsma, Jenny P Tsai, Navdeep Sangha, Osman Kozak, Daniel Gibson, Steven Warach, Dennis Cordato, Nathan W Manning , Timothy J Kleinig, JeanMarc Olivot , Lucas Elijovich , Georgios Tsivgoulis, Andrei Alexandrov, Pascal Jabbour , Bernard Yan, Scott E Kasner, Adam S Arthur , Mark Parsons, James C Grotta, Ameer E Hassan , Gregory W Albers, On behalf of SELECT2 Investigators and SELECT2 Steering Committee
Journal of neurosurgical anesthesiology, Jan 31, 2018
Anesthetic modality and hemodynamic management during mechanical thrombectomy (MT) for acute isch... more Anesthetic modality and hemodynamic management during mechanical thrombectomy (MT) for acute ischemic stroke (AIS) are potential contributors to the success of revascularization. The aims of our study were to review the hemodynamic management by anesthesiologists and clinical outcomes in patients undergoing MT under conscious sedation. Retrospective cohort study of patients with anterior circulation AIS from January 2012 to March 2016. Primary outcome was hemodynamic intervention, defined as administration of vasoactive drugs to maintain systolic blood pressure (BP) between 140 and 180 mm Hg. The secondary outcome was poor hemodynamic control, defined as BP outside target for >15 minutes despite hemodynamic intervention. We performed regression analysis to determine the predictors of hemodynamic intervention and poor hemodynamic control. A total of 126 patients were included in this study; 92% (116) receiving conscious sedation and 8% (10) no sedation. Upon arrival to the neurora...
Journal of the Neurological Sciences, 2003
Objectives: Patients with Parkinson's disease (PD) have an increased risk of falling that has yet... more Objectives: Patients with Parkinson's disease (PD) have an increased risk of falling that has yet to be fully explained. To better understand the gait disturbance in PD and the factors that contribute to falls, we quantitatively evaluated: (1) the relationship between gait variability (a marker of fall risk in other populations), fall history, and other parkinsonian features, and (2) the effects of levodopa on these relationships. Methods: The average stride time and stride-to-stride variability were measured using force-sensitive insoles during comfortable walking. Fall frequency, motor control, function, and mental health were measured using the Unified Parkinson's Disease Rating Scale (UPDRS), the Mini-Mental State Exam (MMSE), and the timed motor tests of the Core Assessment Program for Intracerebral Transplantations (CAPIT) in 32 subjects with idiopathic PD, in an ''off'' (unmedicated) state and again in an ''on'' (medicated) state. Results: Average stride time was not associated with any UPDRS or CAPIT measure and was similar in fallers and non-fallers in ''off'' and ''on'' states (p > 0.27). Stride time variability was significantly associated with fall frequency as well as with total scores on the CAPIT and the UPDRS, ADL abilities, and motor function. Stride time variability and falls were not related to tremor, rigidity or bradykinesia in the ''off'' state. 41% of subjects reported one or more falls. Stride time variability was 8.8 F 7.9% in fallers and 4.2 F 1.3% in non-fallers (p < 0.009). Stride time variability significantly improved in response to levodopa, both in fallers and non-fallers, but remained increased in fallers (vs. non-fallers). Conclusions: The patho-physiology responsible for impaired stride-to-stride regulation of gait timing is apparently independent of other cardinal features of PD, i.e., tremor, rigidity, or bradykinesia, but is responsive to levodopa. Stride-to-stride variability is especially impaired among PD subjects with a history of falls, suggesting, for the first time, the possibility of exaggerated impairment of internal clock function in PD fallers.
Journal of Clinical Neuroscience, 2003
Background: The pathophysiology of freezing of gait (FOG) is unclear. Objective: To assess the re... more Background: The pathophysiology of freezing of gait (FOG) is unclear. Objective: To assess the relationships between FOG and other parkinsonian features in Parkinson's disease (PD), focusing on levodopa effects. Methods: Nineteen PD patients with significant FOG in "off" were assessed while "off" and "on". Three observers independently viewed videotapes of a 130-m walk and scored FOG frequency. The Unified Parkinson's disease Rating Scale was used to evaluate clinical state. Results: FOG frequency was not correlated with other parkinsonian features in "off" and only with speech and writing in "on". Levodopa significantly decreased FOG frequency (p < 0:001). This reduction was strongly correlated with improvement of tremor (R ¼ 0:80, p < 0:01) and speech (R ¼ 0:62, p < 0:05), but not with improvement in rigidity, bradykinesia, or balance. Conclusion: Levodopa decreases FOG in PD. FOG is apparently an independent motor symptom, caused by a paroxysmal pathology that is different from that responsible for bradykinesia, rigidity or postural instability.
American Journal of Neuroradiology, 2008
BACKGROUND AND PURPOSE: The long-term fate of coiled intracranial aneurysms is largely unknown, a... more BACKGROUND AND PURPOSE: The long-term fate of coiled intracranial aneurysms is largely unknown, and prolonged imaging follow-up has been advocated. The yield of follow-up imaging in coiled aneurysms adequately occluded at 6 months is unknown. In such patients, we performed time-of-flight MR angiography (MRA) to assess the incidence and therapeutic consequences of reopening 5-11 years after coiling. MATERIALS AND METHODS: Between 1995 and 2002, 661 aneurysms in 607 patients were coiled in 3 participating centers. Six-month follow-up angiograms were obtained in 497 (75%) aneurysms, of which 316 (64%) in 297 patients were adequately occluded. Of 297 patients, 84 were excluded for various reasons and 73 could not be traced. Of 140 eligible patients, 104 (74%) with 111 aneurysms were studied with 3T MR imaging and high-resolution MRA at a mean of 6.0 years after coiling (median, 5.6 years; range, 5.0-10.6 years). RESULTS: The proportion of aneurysms with reopening was 3.6% (4/111; 95% confidence interval [CI], 1.1%-9.2%). One reopened aneurysm, which initially contained intraluminal thrombus, was additionally coiled (0.9%; 95% CI, 0.0%-5.4%).
American Journal of Neuroradiology, 2009
BACKGROUND AND PURPOSE: MR angiography (MRA) is increasingly used as a noninvasive imaging techni... more BACKGROUND AND PURPOSE: MR angiography (MRA) is increasingly used as a noninvasive imaging technique for the follow-up of coiled intracranial aneurysms. However, the need for contrast enhancement has not yet been elucidated. We compared 3D time-of-flight MRA (TOF-MRA) and contrastenhanced MRA (CE-MRA) at 3T with catheter angiography. MATERIALS AND METHODS: Sixty-seven patients with 72 aneurysms underwent TOF-MRA, CE-MRA, and catheter-angiography 6 months after coiling. Occlusion status on MRA was classified as adequate (complete and neck remnant) or incomplete by 2 independent observers. For TOF-MRA and CE-MRA, interobserver agreement, intermodality agreement, and correlation with angiography were assessed by statistics. RESULTS: Catheter-angiography revealed incomplete occlusion in 12 (17%) of the 69 aneurysms; 3 aneurysms were excluded due to MR imaging artifacts. Interobserver agreement was good for CE-MRA ( ϭ 0.77; 95% confidence interval [CI], 0.55-0.98) and very good for TOF-MRA ( ϭ 0.89; 95% CI, 0.75-1.00). Correlation of TOF-MRA and CE-MRA with angiography was good. The sensitivity of TOF-MRA and CE-MRA was 75% (95% CI, 43%-95%); the specificity of TOF-MRA was 98% (95% CI, 91%-100%) and of CE-MRA, 97% (95% CI, 88%-100%). All 5 incompletely occluded aneurysms, which were additionally treated, were correctly identified with both MRA techniques. Areas under the receiver operating characteristic curve for TOF-MRA and CE-MRA were 0.90 (95% CI, 0.79 -1.00) and 0.91 (95% CI, 0.79 -1.00). Intermodality agreement between TOF-MRA and CE-MRA was very good ( ϭ 0.83; 95% CI, 0.65-1.00), with full agreement in 66 (96%) of the 69 aneurysms. In this study, TOF-MRA and CE-MRA at 3T were equivalent in evaluating the occlusion status of intracranial aneurysms after coiling. Because TOF-MRA does not involve contrast administration, this method is preferred over CE-MRA.
Abstract TP112: Mechanism of Recurrent Stroke in Patients with Atherosclerotic Vertebrobasilar Disease in Relation to Hemodynamics
Stroke, 2017
Objectives: Patients with symptomatic atherosclerotic vertebrobasilar disease are at high risk fo... more Objectives: Patients with symptomatic atherosclerotic vertebrobasilar disease are at high risk for recurrent stroke and we have demonstrated that distal flow status is independently associated with this risk. Our aim was to assess the mechanism of recurrent strokes in these patients related to their distal flow status. Methods: Patients with symptomatic atherosclerotic vertebrobasilar disease were enrolled in a prospective longitudinal cohort study (VERiTAS) with a median follow-up of 23 months. Large-vessel flow in the posterior circulation distal to the stenosis and/or occlusion was measured on quantitative MR angiography and dichotomized into normal or low flow. Three observers, who were blinded to the distal flow status, independently reviewed the imaging done at the time of the recurrent stroke to classify the most likely stroke mechanism. Results: Ten out of 72 enrolled patients had a recurrent stroke in the posterior circulation. Four patients were determined to have embolic ...
Clinical Reasoning: A 65-Year-Old Woman With New Headache, Pulsatile Tinnitus, and Visual Disturbances
Neurology
Endovascular Treatment Versus Best Medical Therapy in Acute Ischemic Stroke Patients with Mild Symptoms
World Neurosurgery
Association of initial imaging modality and futile recanalization after thrombectomy
Neurology
ObjectiveTo test the hypothesis that selection by initial imaging modality (MRI vs CT) is associa... more ObjectiveTo test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FR) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT, NCT03496064).MethodsIn 2011 patients (49.7% female, median age 73 [61–81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FR were defined as 90 days modified Rankin Scale (mRS) 4–6 despite successful recanalization in patients selected by MRI (N = 690) and CT (N = 1,321) with a sensitivity analysis considering only patients with mRS 5–6 as futile.ResultsMRI as compared to CT resulted in similar rates of subsequent MT (aOR 1.048, 95% CI 0.677–1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4–6 including 393/1,489 (26%) FR mRS 5–6. CT based selection was associated with increased rates of futile recanalizations compared to MRI (44% [41...
Abstract WP44: Comparison of Multi-modal CT Imaging Protocols Used for Decision-Making on Endovascular Treatment in Patients With Acute Ischemic Stroke
Stroke
Per-region interobserver agreement of Alberta Stroke Program Early CT Scores (ASPECTS)
Journal of NeuroInterventional Surgery
Background and purposeThe Alberta Stroke Program Early CT Score (ASPECTS) is a commonly used scor... more Background and purposeThe Alberta Stroke Program Early CT Score (ASPECTS) is a commonly used scoring system to select patients with stroke for endovascular treatment (EVT). However, the inter- and intra-reader variability is high.ObjectiveTo determine whether the inter- and intra-reader variability is different for various regions of the ASPECTS scoring system by evaluating the interobserver variability of ASPECTS between different readers in a per-region analysis.Materials and methodsAll patients with acute ischemic stroke who proceeded to EVT in our institutions over a 4-year period were retrospectively identified from a prospectively maintained database. Images were reviewed by two experienced neuroradiologists, who recalculated the ASPECTS independently. We examined each region of the ASPECTS system to evaluate agreement between the raters in each area.Results375 patients were included. The median total ASPECTS was 9 (IQR 8–9). The most common region showing ischemic change was ...
Stroke
Background and Purpose— We aimed to determine the safety and mortality after mechanical thrombect... more Background and Purpose— We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods— In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results— Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62–82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35–4.84]...
Comparison of multimodal CT scan protocols used for decision-making on mechanical thrombectomy in acute ischemic stroke
Neuroradiology
Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial
The Lancet